Society of Transplantation Update on Transplantation and Instructional Course - "Frontiers in Transplantation"

06 Oct 2006

By Ms Yong Ying-I, Permanent Secretary (Health)

Venue: Oriental Hotel

Dr Lye Wai Chong

President, Society of Transplantation

Assoc Prof Vathsala

Vice-president,

Distinguished Guests

Ladies and gentlemen

Introduction

It gives me great pleasure to be here this evening to open the Society of Transplantation's Update on Transplantation and Instructional Course.  I would like to congratulate the Society for assembling a very distinguished faculty of speakers and bringing together all the healthcare professionals involved in the management of renal failure.  I am sure that the update sessions will be spirited and fruitful.

The theme for the Update - "Frontiers in Transplantation" is timely.  Transplantation will play an increasing part in our efforts to tackle the problem of end-stage renal failure.  Medical advances in the field will bolster our efforts to help these patients lead meaningful and productive lives.

Promoting Renal Transplantation

I understand that the first renal transplant in Singapore was performed in 1970.  Back then, the procedure was very much experimental. But with the development of powerful immunosuppressant drugs in the 1980s, renal transplantation around the world and in Singapore is now considered an established procedure. What has not changed in these three-and-a-half decades, however, is the fact that there continues to be shortage of donor kidneys. Thus many of our patients with end-stage renal failure are not transplanted, but instead maintained on dialysis treatment.

This, of course, is less than ideal for the patients. We know from evidence that renal transplantation is the best treatment option for patients with end-stage renal failure. Renal transplant patients survive longer and are hospitalised less frequently compared to patients on dialysis. Transplant patients are also able to lead a better quality of life and are more able to hold down a job. Compared to dialysis, renal transplantation is also more cost-effective.

Efforts by the Ministry of Health to Increase Organ Donation

In the last two decades, the Ministry of Health has been working hard to increase the availability of donor organs.  First, the Human Organ Transplant Act, a presumed consent law, was introduced in 1987 for the removal of kidneys from persons who died in accidents. The Act was then revised in 2004 to allow for the removal of liver, heart and corneas, in addition to kidneys, and to cover all causes of death. The result is that many more patients have benefited. The number of cadaveric renal transplants increased from 18 in 2003 to 43 in 2005.

Despite this increase, the need for donor kidneys is not met. Today, the 600 patients on our national cadaveric renal transplant waiting list have an average waiting time of about 7 years for a transplant. Every year, over 800 people develop end-stage renal failure, most of whom are placed on dialysis.  About 100 patients enter the transplant waiting list annually.  Each year, about 40 patients on our waiting list drop out from the queue as they become medically unfit to undergo a renal transplant or die from non-renal causes.

Though many countries in the world face similar challenges, a few countries- like Norway- have been more successful.  Norway, for example, has a total renal transplant rate of 50 per million population, compared to 19 per million population in Singapore.  In Norway, 72% of end-stage renal failure patients undergo transplantation. In Singapore, it is the reverse: 73% of end-stage renal failure patients are on dialysis.  There is much for us to learn from those countries which have been successful in their transplant programmes. The Ministry had sent teams to visit some of these countries to learn from their experiences. This year, our staff visited Norway and as a follow up, we have asked the Norway National Transplant Unit to further advise us on how we could improve our programme. I am pleased to welcome Dr Pal-Dag Line, Assistant Chairman of the Norway National Transplant Unit, who is here with us today.

Living Donor Renal Transplantation

On the cadaveric renal transplant front, there is a limit as to how much we can do in view of the finite number of suitable deceased donors each year. The practical alternative is to increase the number of living donors. We are seeing a positive trend -- the number of living donor renal transplants amongst Singaporeans has increased gradually from 16 in 1998 to 23 in 2005. The living donor rates for Singaporeans at 6.5 per million population is, however, still substantially lower than that of 18.9 per million population in Norway. There is quite a ways for us to go.

My view is that public and patient education is the key to a successful living donor kidney transplant programme.  This is why the Ministry of Health has been partnering the Society of Transplantation for several years now to provide public and professional education on transplantation.  This entails informing potential donors of the small but nonetheless real risk of complications, on the one hand, and addressing misconceptions such as organ donation leading to general poor health or the inability to return to work, on the other.  We have also worked together to launch initiatives to highlight the benefits of transplantation, and recognise donors for their generosity.  

Role of VWOs

In the audience this evening, I see familiar faces from the VWO-community. Besides providing dialysis services, they have been at the forefront with us in promoting transplantation.  For example, as early as the formulation of the Human Organ Transplant Act, the National Kidney Foundation played a major role in garnering support for the legislation. For living donor renal transplantation, a "Donor Fund" has recently been set up, in addition to government subsidies, by the Kidney Dialysis Foundation and the Khoo Foundation to assist needy donors with the costs of hospitalisation and kidney donation surgery. "A Bridge To Transplant" programme was set up by the Kidney Dialysis Foundation to allow dialysis patients easier access to subsidised dialysis while their kidney donors undergo evaluation. Here, I would like to acknowledge and commend the VWOs for their support, and ask that you continue to encourage your dialysis patients to consider living donor transplantation.

VWOs have a huge capacity to reach out to their patients and to the community-at-large through their centres and their professional staff.  The provision of dialysis services is not the sole purpose.  It should instead be the reduction of the burden of end-stage renal failure in which transplantation plays a major part. VWOs could do this through the pooling of their resources to continue to support living donor transplantation through educational and financial programmes.

Role of the Ministry of Health

On our part, MOH has reviewed our national strategy for managing end-stage renal failure. After amending the Human Organ Transplant Act, our next focus is on promoting living donor transplantation. My Minister strongly encouraged us to learn from other countries which had done well in living donor transplantation, and invite their experts to come to Singapore to help in our professional efforts.  Earlier this year, I had also asked my staff to help gather all the stakeholders together so that we could unite behind this common cause.  I am glad that at this event, both of these ideas have come together. 

The Ministry has also just launched a Health Service Development Project in SGH, NUH and TTSH, aiming to increase living donor renal transplantation rates.   In this pilot project, every case of newly diagnosed end-stage renal failure will be worked up first by a dedicated transplant counselor to determine if a living donor renal transplant is possible. Previously, the patient would have to speak to his family members and relatives about being donors.  The transplant counselor now will play a major role in these discussions. Only if transplantation is not possible, will the case be referred to the dialysis providers.  By this, we hope to gradually increase our living donor renal transplant rate. Besides this programme, the Ministry will be intensifying transplant training for both doctors and transplant coordinators. 

All these efforts will not be enough, however, if the numbers of new end-stage renal failure cases are not reduced. In Singapore, diabetic renal disease accounts for half of our new cases of end-stage renal failure.  Just this month, we launched the Medisave for Chronic Disease Management Programme. This is not just about patients being able to access Medisave for diabetes, hypertension, lipid disease and stroke.  An integral part of this programme is the raising of care standards for these conditions through patient education, co-ordinated care and clinical monitoring. With improved diabetes care and increased renal transplantation, it is our hope that fewer of our patients will end up with end-stage renal failure, and that the burden of the disease to society will be markedly reduced. 

The Power of Love

We must never forget that behind all our efforts is the human face of the suffering caused by end-stage renal failure. I wonder how many of you recall an article highlighted in The New Paper in April this year, which carried a touching story in which a healthy lady had donated one of her kidneys to her adopted older step-sister. The recipient Mdm Naemah, was adopted as an infant by Mdm Normah's father. Mdm Normah said that it broke her heart to see her elder sister Mdm Naemah falling sick. Mdm Naemah would feel tired often and vomit when she returned home from her dialysis sessions. The younger sister then decided that she had to do something to make life better for Mdm Naemah. She wanted Mdm Naemah to be able to go out and "jalan jalan" with her like before, and she took the brave step.

Conclusion

To conclude, I would like to commend the Society of Transplantation for partnering the Ministry, and making its annual scientific meeting a platform for furthering the cause of renal transplantation.  By working together can the Ministry, the Society and the VWOs explore new frontiers in transplantation.  We can together help to create many more happy stories like Mdm Naemah's. I wish you all a most productive and enjoyable time at this update.

Thank you.