Renal replacement therapy in Europe: a summary of the 2012 ERA-EDTA Registry Annual Report.

BACKGROUND: This article summarizes the 2012 European Renal Association-European Dialysis and Transplant Association Registry Annual Report (available at www.era-edta-reg.org) with a specific focus on older patients (defined as ≥65 years). METHODS: Data provided by 45 national or regional renal registries in 30 countries in Europe and bordering the Mediterranean Sea were used. Individual patient level data were received from 31 renal registries, whereas 14 renal registries contributed data in an aggregated form. The incidence, prevalence and survival probabilities of patients with end-stage renal disease (ESRD) receiving renal replacement therapy (RRT) and renal transplantation rates for 2012 are presented. RESULTS: In 2012, the overall unadjusted incidence rate of patients with ESRD receiving RRT was 109.6 per million population (pmp) (n = 69 035), ranging from 219.9 pmp in Portugal to 24.2 pmp in Montenegro. The proportion of incident patients ≥75 years varied from 15 to 44% between countries. The overall unadjusted prevalence on 31 December 2012 was 716.7 pmp (n = 451 270), ranging from 1670.2 pmp in Portugal to 146.7 pmp in the Ukraine. The proportion of prevalent patients ≥75 years varied from 11 to 32% between countries. The overall renal transplantation rate in 2012 was 28.3 pmp (n = 15 673), with the highest rate seen in the Spanish region of Catalonia. The proportion of patients ≥65 years receiving a transplant ranged from 0 to 35%. Five-year adjusted survival for all RRT patients was 59.7% (95% confidence interval, CI: 59.3-60.0) which fell to 39.3% (95% CI: 38.7-39.9) in patients 65-74 years and 21.3% (95% CI: 20.8-21.9) in patients ≥75 years.

Conservative care in Europe--nephrologists' experience with the decision not to start renal replacement therapy.

BACKGROUND: For some patients with end-stage renal disease (ESRD), providing conservative care until death may be an acceptable alternative for renal replacement therapy (RRT). We aimed to estimate the occurrence of conservative care in Europe and evaluated opinions about which factors nephrologists consider important in their decision not to offer RRT. METHODS: With a web-based survey sent to nephrologists in 11 European countries, we inquired how often RRT was not started in 2009 and how specific factors would influence the nephrologists' decision to provide conservative care. We compared subgroups by nephrologist and facility characteristics using chi-square tests and Mann-Whitney U tests. RESULTS: We received 433 responses. Nephrologists decided to offer conservative care in 10% of their patients [interquartile range (IQR) 5-20%]. An additional 5% (IQR 2-10%) of the patients chose conservative care as they refused when nephrologists intended to start RRT. Patient preference (93%), severe clinical conditions (93%), vascular dementia (84%) and low physical functional status (75%) were considered extremely or quite important in the nephrologists' decision to provide conservative care. Nephrologists from countries with a low incidence of RRT, not-for-profit centres and public centres more often scored these factors as extremely or quite important than their counterparts from high-incidence countries, for-profit centres and private centres. CONCLUSIONS: Nephrologists estimated conservative care was provided to up to 15% of their patients in 2009. The presence of severe clinical conditions, vascular dementia and a low physical functional status are important factors in the decision-making not to start RRT. Patient preference was considered as a very important factor, confirming the importance of extensive patient education and shared decision-making.

Renal replacement therapy in Europe-a summary of the 2010 ERA-EDTA Registry Annual Report.

BACKGROUND: This study provides a summary of the 2010 European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry Annual Report (available at www.era-edta-reg.org). METHODS: This report includes data on renal replacement therapy (RRT) using data from the national and regional renal registries in 29 countries in Europe and bordering the Mediterranean Sea. Individual patient data were received from 27 registries, whereas 18 registries contributed data in aggregated form. We present incidence and prevalence of RRT, transplant rates, survival probabilities and expected remaining lifetimes. The latter two are solely based on individual patient records. RESULTS: In 2010, the overall incidence rate of RRT for end-stage renal disease (ESRD) among all registries reporting to the ERA-EDTA Registry was 123 per million population (pmp) (n = 91 798). The highest incidence rate was reported by Turkey (252pmp) and the lowest reported by Montenegro (21 pmp). The overall prevalence of RRT for ESRD at 31 December 2010 among all registries reporting to the ERA-EDTA Registry was 741 pmp (n = 551 005). The prevalence varied from 124 pmp in Ukraine to 1580 pmp in Portugal. The overall number of renal transplantations performed in 2010 among all registries was 29.2 pmp (n = 21 740). The highest overall transplant rate was reported from Spain, Cantabria (73 pmp), whereas the highest transplant rate for living donor kidneys was reported from the Netherlands (28 pmp). For patients who started RRT between 2001 and 2005, the unadjusted 5-year patient survival on RRT was 46.2% [95% confidence interval (CI) 46.0-46.3], and on dialysis 38.6% (95% CI 38.5-38.8). The unadjusted 5-year patient survival after the first renal transplantation performed between 2001 and 2005 was 86.6% (95% CI 86.1-87.1) for deceased donor kidneys and 94.1% (95% CI 93.4-94.8) for living donor kidneys.

Factors influencing the decision to start renal replacement therapy: results of a survey among European nephrologists.

BACKGROUND: Little is known about the criteria nephrologists use in the decision of when to start renal replacement therapy (RRT) in early referred adult patients. We evaluated opinions of European nephrologists on the decision for when to start RRT. STUDY DESIGN: European web-based survey. PREDICTORS: Patient presentations described as uncomplicated patients, patients with unfavorable clinical and unfavorable social conditions, or patients with specific clinical, social, and logistical factors. SETTING & PARTICIPANTS: Nephrologists from 11 European countries. OUTCOMES & MEASUREMENTS: We studied opinions of European nephrologists about the influence of clinical, social, and logistical factors on decision making regarding when to start RRT, reflecting practices in place in 2009. Questions included target levels of kidney function at the start of RRT and factors accelerating or postponing RRT initiation. Using linear regression, we studied determinants of target estimated glomerular filtration rate (eGFR) at the start of RRT. RESULTS: We received 433 completed surveys. The median target eGFR selected to start RRT in uncomplicated patients was 10.0 (25th-75th percentile, 8.0-10.0) mL/min/1.73 m(2). Level of excretory kidney function was considered the most important factor in decision making regarding uncomplicated patients (selected by 54% of respondents); in patients with unfavorable clinical versus social conditions, this factor was selected by 24% versus 32%, respectively. Acute clinical factors such as life-threatening hyperkalemia refractory to medical therapy (100%) and uremic pericarditis (98%) elicited a preference for an immediate start, whereas patient preference (69%) and vascular dementia (66%) postponed the start. Higher target eGFRs were reported by respondents from high- versus low-RRT-incidence countries (10.4 [95% CI, 9.9-10.9] vs 9.1 mL/min/1.73 m(2)) and from for-profit versus not-for-profit centers (10.1 [95% CI, 9.5-10.7] vs 9.5 mL/min/1.73 m(2)). LIMITATIONS: We were unable to calculate the exact response rate and examined opinions rather than practice for 433 nephrologists. CONCLUSIONS: Only for uncomplicated patients did half the nephrologists consider excretory kidney function as the most important factor. Future studies should assess the weight of each factor affecting decision making.

Decreasing trends in incidence and prevalence of renal replacement therapy in Croatia from 2000 to 2009.

BACKGROUND: Recent studies have indicated stabilization in the incidence rates of renal replacement therapy (RRT) for end-stage renal disease (ESRD) in a number of European countries, the USA, and Japan. The aim of this study was to provide an update on the incidence and prevalence trends of RRT in Croatia over the past decade. METHODS: Data from the Croatian Registry of Renal Replacement therapy from 2000 to 2009 were analysed. Trends in incidence and prevalence were examined using the Poisson regression and Joinpoint regression analysis. RESULTS: The total adjusted incidence rate of RRT for ESRD increased from 106.1 per million population (pmp) in 2000 to 140.4 pmp in 2004, at annual percentage change (APC) 7.0% [95% confidence interval (CI) 1.8, 12.6]. From 2004 to 2009, there was no rise in incidence [APC -1.0 (95% CI -4.5, 2.6)]. Continuous growth in incidence was present only in males [APC 2.6 (95% CI 0.9, 4.4)], in patients 65 years and older [APC 5.5 (95% CI 3.4, 7.6)], in patients with diabetes [APC 2.4 (95% CI 0.5, 4.4)], hypertension/renovascular disease [APC 6.1 (95% CI 1.6, 10.8)] and unknown/missing diagnosis [APC13.8 (95% CI 9.0, 18.8)]. The total adjusted prevalence rate rose from 598.7 pmp in 2000 to 785.6 pmp in 2004, at an annual rise of 7.5% (95% CI 5.8, 9.3). In the 2004-09 period, the growth of RRT slowed to APC 2.4 (95% CI 1.2, 3.5), and reached 890.8 pmp in 2009. CONCLUSIONS: After a rapid increase in the incidence of RRT in Croatia from 2000 to 2004, the incidence rate has stabilized during the 2004-09 period. The stabilization of incidence is followed by a reduction in the growth in prevalence rate. The stabilization of RRT incidence could be attributed to the successful prevention and treatment of cardiovascular diseases that simultaneously improved renal survival.

Peritoneal dialysis in Croatia.

OBJECTIVE: To present the state of renal replacement therapy (RRT) in Croatia, assess the quality of dialytic treatment, verify the value of peritoneal dialysis (PD), and promote expansion of PD in Croatia based on results attained locally. According to the integrative care concept, PD is the best way to start life-long RRT. Croatian nephrologists have adopted the policy of increasing the use of PD. However, evidence for recommendations were obtained in specific circumstances and might not be relevant elsewhere. The aim of this observational study is to compare the outcome of PD with that of hemodialysis (HD), as practiced in Croatia. METHODS: Since 2000, the Croatian Registry for Renal Replacement Therapy has been collecting individual patient data for all patients on RRT, with complete coverage. RESULTS: As of 31 December 2004, there were 251 prevalent patients on PD (continuous ambulatory PD and automated PD) in Croatia, accounting for 7% of all patients on RRT and giving a prevalence of 57 patients per million population. From 1 January 2000 to 31 December 2004, 377 patients started PD and were followed from the first day of RRT. For 80% of them, PD was the first mode of RRT. The probability of staying on PD for 5 years was 31% [95% confidence interval (CI) 29-32]. Five-year technique survival (excluding transplanted, recovered, and deceased patients) was 68% (95%CI 65-70). For survival analysis and comparison between PD and HD, only patients on the same method from the start of their RRT were included. Patients changing treatment were censored after 60 days (intention-to-treat analysis). Unadjusted 5-year survival in the PD-first group (301 patients) was 60% (95%CI 54-65), which is significantly better than in the 2789 HD-first patients (42%, 95%CI 40-44; log-rank p < 0.0001). When data were stratified for age and diabetes, 5-year mortality rates on HD were higher in all strata. Only in patients >/=70 years old was the advantage of PD less impressive. Standardized mortality ratio was 1.85 (p < 0.01) in favor of PD. Hazard ratio of HD versus PD was 2.1 (95%CI 1.6-2.8). After adjustments for age, gender, diabetes, and nephroangiosclerosis, the hazard ratio settled at 1.5 (95%CI 1.1-1.9). CONCLUSION: In Croatia, PD is used mostly as the first RRT. Almost one third of patients continue PD for 5 years due to good patient and technique survival. Starting RRT with PD offers 50% superior 5-year survival in comparison to HD. Dialysis patients in Croatia would benefit from an expanded PD program.

Ocular findings in patients with chronic renal failure undergoing haemodialysis.

The aim of this paper was to evaluate the ocular findings in patients with chronic renal failure (CRF) undergoing haemodialysis (HD). In 64 patients undergoing haemodialysis (30 female and 34 male), aged 24-83 years (mean 58 years) on haemodialysis 1-213 months (mean 47 months) complete ocular examination were performed: visual acuity (VA), intraocular pressure (IOP), biomicroscopic examination and fundoscopy. On right eye sixty-nine percent of patents had VA 0.6 or better, and on left eye 84% of patients had VA 0.6 or better. Mean IOP before dialysis was 15 mmHg and after dialysis was 14 mmHg. In 9 patients (14%) we found corneo-conjunctival calcium deposits. No correlation of ocular calcification and parathyroid hormone (PTH) level or calcium and phosphate product were observed. 39 (60%) patients had cataract. Hypertensive vascular changes were seen in 44 (68%) patients and in 6 (7%) patients age-related macular degeneration. Seven patients had diabetes mellitus and in 5 diabetic retinopathy was observed. Patients with CRF or who are receiving HD represent unique group of patients. Pathologic change could be found in many tissue and organs, therefore we suggest ocular examination more frequently in dialysis patients.