Kidney disease is on the rise. Can Singapore’s healthcare system keep up with the demand?
As the afternoon session kicks off at a National Kidney Foundation (NKF) dialysis centre in Ang Mo Kio, 68-year-old Mr Amer Mohamed prepares his own dialysis machine while nurses bustle around, ensuring the room is ready for the next patients.
Mr Amer has been on dialysis for about 13 years, attending four-hour sessions three times a week. In the past six months, however, he has started setting up his own haemodialysis (HD) machine at the start of each session.
He recalls the early days as a daunting challenge, taking roughly three months to become familiar with the process.
“I really almost gave up. There’s a lot to set up.”
Today, he handles most steps independently, including attaching tubes and a dialysate bag, with nurses stepping in to confirm accuracy.
Across NKF’s 45 dialysis centres, which operate for 16 hours daily (closed on Sundays), Mr Amer is part of a broader push to help facilities cope with growing demand that has stretched resources thin.
He is among 274 patients deemed competent to manage certain procedures on their own under a self-care management programme, which frees nurses to focus on patients with more complex needs.
Patients like Mr Amer require haemodialysis because their kidneys can no longer remove waste and toxins, risking permanent damage to cells, tissues, and organs.
The treatment cleanses the blood of toxins, excess salt, and fluids, and is essential if a kidney transplant is not available. The Ministry of Health (MOH) overall waiting list reached 397 people for a kidney transplant as of June last year, with an average 2023 wait time of about nine years.
During dialysis, patients lie or sit beside a machine while two large needles insert into one arm—one to remove unfiltered blood and the other to return filtered blood.
Six new patients begin dialysis each day, NKF’s statistics show—three times the rate seen two decades ago.
THE ECONOMIC BURDEN
The surge in kidney disease stands out when compared with other chronic conditions.
The MOH and Health Promotion Board’s 2024 National Population Health Survey found that while diabetes, hypertension, and high cholesterol remained stable or declined, chronic kidney disease rose sharply—from 8.7% (2019–2020) to 14.9% (2023–2024).
Experts attribute this jump to resumed blood and urine testing after the COVID-19 pandemic and proactive screening of high-risk patients. Adjunct Associate Professor Dr Chua Horng Ruey, head of nephrology at NUH, notes these factors likely contributed to increased detection.
Kidney disease imposes a significant financial burden, with more than S$330 million (US$255 million) spent annually on dialysis nationwide.
Dialysis in Singapore is heavily subsidised for low-income patients. The Renal Registry Report 2023 shows that 65.8% of patients receive dialysis through voluntary welfare organisations like NKF, 32.5% through private centres, and the rest through public hospitals or affiliated centres. About nine in ten subsidised patients pay nothing out of pocket.
At NKF, most patients pay no more than S$50 per month, and 40% pay nothing at all out of pocket.
With rising patient numbers and increasing case complexity, NKF’s costs have nearly tripled—from S$67.6 million in FY2014/15 to S$180 million in FY2024/25.
In 2023, NKF spent around S$143 million on support for more than 5,500 patients, with government subsidies covering over 40% and charitable donations contributing about 20%. About 30% of expenses were funded by MediShield Life and MediSave, and the remaining 10% came largely from out-of-pocket payments.
Yet as operating costs and patient numbers climb, leaders warned that charity funds won’t keep pace forever. Without additional measures, patient costs may rise.
Other subsidised providers voice sustainability concerns, including Kidney Dialysis Foundation (KDF) and Ihsan Kidney Care (IKC), which warn that growing kidney failure rates require steady, long-term funding for low-income patients.
WHY THE SURGE?
The rise in kidney disease correlates with Singapore’s most common chronic conditions—diabetes, hypertension, and cardiovascular disease.
Singapore ranks third globally for diabetes-related kidney failure, and roughly two-thirds of NKF patients developed kidney failure due to diabetes.
An ageing population with more cardiovascular disease widens the pool of individuals at risk. Yet there is a glimmer of progress: diabetes-related kidney failure among new dialysis patients declined from about 68% in 2019 to 63% in 2023, a modest but hopeful sign that national efforts like the Beat Diabetes campaign may be paying off.
Beyond medical factors, lifestyle choices also contribute. Diets high in sodium, frequent dining out with hidden salt and sugar, and overall caloric excess drive high blood pressure and obesity—both kidney risk factors. Clinicians also note rising BMI among younger adults (ages 30–39), with research linking high BMI to future kidney failure.
Late detection and low awareness compound the issue, especially for lower-income families who face earlier onset and more advanced disease. IKC emphasizes the role of diet quality, affordable but unhealthy foods, and limited health literacy in treatment adherence.
The financial strain and dialysis logistics add to the challenge, particularly for those with transportation costs and fatigue that impede work.
Some patients delay or skip sessions due to these burdens. For instance, Ms Florence Amertu A Joseph, 63, relied on a S$335 transport allowance but eventually moved closer to a centre to shorten commutes; the four-hour sessions still limit employment opportunities.
Ethnic disparities are evident, with the Malay community bearing the highest CKD prevalence (20.2%), representing 27.5% of Singapore’s dialysis population despite making up 13.5% of residents. Lower screening rates, higher smoking, and less physical activity contribute to later detection and greater disease burden in this group.
MORE CENTRES ARE NOT THE ANSWER
Expanding dialysis facilities is increasingly difficult. NKF now runs 45 centres, up from 28 a decade ago, yet rising patient needs strain resources. Dialysis costs per patient have risen from about S$26,000 to roughly S$35,000 annually, driven more by case complexity than inflation.
As Singapore’s population ages, many patients are frail or have multiple chronic conditions, requiring more intensive support ranging from medications and transport to physiotherapy and emotional care.
NKF currently has about 40 patients on a waiting list across eight centres in the north, with wait times ranging from months to years.
Expanding capacity via new centres is not viewed as a sustainable solution. Lead times for building facilities run for years, which cannot keep pace with demand. Instead, NKF plans to retrofit existing facilities and optimise use, including expanding nocturnal dialysis.
If nocturnal dialysis could be offered across NKF’s remaining centres, capacity could rise by about 2,000 patient slots, though higher operating costs and staffing remain constraints.
Other providers also cite workforce pressures and rising renal-trained staff costs.
KEEPING KIDNEY DISEASE IN CHECK
Experts advocate a mix of targeted screening for high-risk individuals, early intervention, and system-wide improvements to curb the rising burden.
Public awareness gaps are evident in patients like Miss Ivy Ng Peixin, 27, diagnosed with kidney failure in 2021 at 23. Ng has built a following on TikTok, educating followers through live dialysis sessions and debunking myths about dialysis as a life-saving treatment.
She notes that preventative education in healthcare is limited, even as she tries to raise awareness online.
NKF has taken steps to boost awareness by screening for estimated glomerular filtration rate (eGFR), a key measure of kidney function, in addition to expanding education and screening programs. The organisation now reaches over 165,000 people through partnerships with schools, healthcare groups, community groups, and about 200 general practitioners. In a screening of more than 5,600 individuals, around 15% showed abnormalities requiring follow-up—underscoring how many cases may go undetected.
MOH has integrated annual kidney assessments for people with chronic diseases such as diabetes and hypertension into the Healthier SG programme to monitor kidney health.
Investments in technology and operations are helping providers meet rising demand while improving care quality. NKF has introduced haemodiafiltration (HDF), a gentler dialysis option that removes a broader range of toxins, helps stabilise blood pressure, reduces cardiovascular risk, and lowers long-term complications. HDF machines cost about S$30,000, with only 11 centres equipped with two HDF machines each.
To support nocturnal dialysis, NKF has adopted plastic cannulas to replace metal needles, reducing pain and helping patients sleep better. About 450 patients use this approach, though it costs roughly ten times more than traditional needles.
Operational gains are also being achieved through digital tools, such as speech-to-text systems for social workers that cut documentation time and save roughly S$170,000 in costs, freeing staff to spend more time with patients. Other providers report similar digital transformations with significant workflow improvements.
Looking ahead, research will be key to long-term improvements in kidney care. The SGH-NKF Renal Research Fund, a joint initiative between NKF and SGH, has raised S$5.5 million with government match funding to support studies on early detection, disease progression, home therapies, transplantation, and psychosocial support. NUH is also expanding the use of evidence-based therapies for CKD, including ongoing trials of promising new drugs.
HOME-BASED DIALYSIS AS AN OPTION
Besides in-centre haemodialysis, home-based peritoneal dialysis (PD) is another path. PD uses the abdominal lining as a natural filter, with manual exchanges during the day (CAPD) or automated exchanges at night (APD).
MOH continues to promote home-based PD as a preferred option for suitable patients due to convenience and comparable outcomes. The National PD Home Support Programme, launched in 2022, provides home visits by nurses from public hospitals and NKF, with monthly subsidies.
However, PD uptake remains relatively modest: 546 NKF patients are on PD compared with 5,505 who attend centres as of November 30 this year.
MOH is working with public hospitals and dialysis providers to develop pre-dialysis counselling, training, and educational materials to support independent PD.
NUH is also piloting Singapore’s first home haemodialysis program, though early surveys show limited awareness. Some patients report confidence in performing PD at home, but many older patients fear making mistakes if left to manage treatment themselves.
For some patients, the lack of a caregiver makes home-based therapy less feasible. Social perceptions also pose hurdles; for example, Ms Florence notes that people’s questions about abdominal swelling or pregnancy can be hurtful.
Still, others find home dialysis empowering. Ms Katharina Seng, diagnosed with CKD 40 years ago, chose home-based therapy after a transplant failed, appreciating the flexibility to work, exercise, travel, and avoid frequent needles. She credits NKF and hospital staff for support and started a local PD group, PD Warriors, to help others navigate home dialysis. She also emphasizes that misconceptions—such as needing a perfectly sterile home or giving up pets—can be managed with regular cleaning.
There is clearly a need for greater awareness about PD and home-based options, and organizations are continuing to educate the public about this viable path.
Source: CNA/jw/ma
