Nephrol Dial Transplant (2000) 15: 156-160
© 2000 European Renal Association-European Dialysis and Transplant Association
Dialysis and Transplantation News
Changing pattern of end-stage renal disease in central and eastern Europe
sk, Poland,21 CEE Advisory Board in CRF: Vladimir Teplan (Prague, Czech Republic), Zvonimir Puretic (Zagreb, Croatia), Valery Pilotovich (Minsk, Byelorussia), Natalia Tomilina and Irina Tareyeva (Moscow, Russia), Istvan Kiss (Budapest, Hungary), Alexandrou Ciocalteu (Bucarest, Romania), Ljubica Djukanovic (Belgrade, Yugoslavia), Miroslav Mydlik (Kosice, Slovakia), Stefan Krivoshiev (Sofia, Bulgaria), Rado Kveder (Ljubliana, Slovenija), Momir Polenakovic (Skopje, Macedonia), Merike Luman (Talinn, Estonia), Rafail Rozental (Riga, Latvija), Maria Stanaityte (Vilnius, Lithuania) 2 Scientific Advisory Board of the ERA–EDTA Registry: J. Douglas Briggs, Dimitri Tsakiris, Benedicte Stengel, Izhar Khan, Elizabeth H. Jones, Otto Mehls, Joao Pinto dos Santos
Correspondence and offprint requests to:
Prof. Boleslaw Rutkowski, Department of Nephrology, Medical University, Debinki 7, 80-211 Gdask, Poland.
Abstract
Background. The epidemiology of end-stage renal disease (ESRD) is changing all over the world. Particularly dramatic changes of the epidemiology of ESRD have occurred in central and eastern Europe (CEE). The aim of the present study was (i) to document the further expansion of renal replacement therapy (RRT) noted in recent years in CEE and (ii) to analyse in some detail treatment modalities and underlying renal conditions.
Methods. Three independent surveys were performed in 1995, 1997 and 1998. Fifteen CEE countries participated. The data were mainly obtained from national registries which are based on centre and patient questionnaires.
Results. The data collected from 15 CEE countries document further expansion of RRT in this region. The report includes data on the availability of RRT in Byelorussia, Estonia, and Russia which have become available for the first time. The epidemiology of dialysed patients has changed remarkably. In the majority of countries the number of diabetic patients has increased, most dramatically so in the Czech Republic (31% of all dialysed patients), in the majority of the other countries 10–14%. The number of ESRD patients with the diagnosis of hypertensive nephropathy has also increased and this was accompanied by an increase in proportion of elderly (>65 years) patients, i.e. 46% in the Czech Republic and 12–25% in most other countries.
Conclusion. Dramatic changes of the availability of RRT treatment have occurred in central and eastern Europe. The proportion of diabetic nephropathy and elderly patients has risen. Large differences in RRT exist between individual CEE countries and this appears mainly dependent on the level of economic development.
Keywords: ESRD epidemiology; diabetic nephropathy; central and eastern Europe; renal replacement therapy
Introduction
Three years ago [1] we reported on the epidemiology of end-stage renal disease (ESRD) and renal replacement therapy (RRT) in countries of central and eastern Europe (CEE). The evolution of RRT has recently gained momentum and notable changes in the composition of the patient population and in the use of different treatment modalities have occurred.
In the past reports have been incomplete to the extent that reliable data from Russia had not been available.
The present report gives an update on the epidemiology of RRT in the CEE countries, gives for the first time data concerning Russia, and details the epidemiology of some underlying renal diseases.
Subject and methods
The data are based on three independent surveys performed in 1995, 1997 and 1998 by the CEE Advisory Board on chronic renal failure. Special questionnaires were filled in by the members of the board using data from the national registries or collection of information from local renal units. National reports based on annual centre, or centre and patient, questionnaires were used for verification [2–5] and, in addition, national registries or their board members were contacted. Data concerning the period 1990–1992 were verified using ERA–EDTA Registry reports [6,7]. The data were also analysed by the Scientific Advisory Board (SAB) of the ERA–EDTA Registry. The data concerned 14 countries, i.e. Bulgaria, Byelorussia, Croatia, Czech Republic, Estonia, Hungary, Latvija, Lithuania, Macedonia, Poland, Romania, Slovakia, Slovenia, Yugoslavia subject to detailed analysis. In addition, the first comprehensive data from Russia were included which were collected by a special team of the Russian Society of Nephrology and concerned the year 1998.
Results
The current state of renal replacement therapy in the CEE countries is given in Table 1.
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In the 14 countries (excluding Russia) 38860 patients were on RRT at the end of 1998, i.e. 293 pmp. Of these 78% were treated with different modalities of dialysis and 22% lived with a functioning graft. If Russia was included, the respective figures would be 46759 patients and 166 pmp respectively.
The proportion of transplanted patients differs between countries. The percentage is lowest in Slovakia, Bulgaria and Yugoslavia, intermediate in Russia, Croatia, Byelorussia or Macedonia, good in the Czech Republic, Hungary and Poland and best in the Baltic countries (Estonia, Latvija, Lithuania).
In the CEE countries the average incidence of patients admitted for RRT was 77 pmp, but in nearly half the countries it exceeded 100 pmp. Although progress has been achieved in the past few years in many countries, a very low incidence, i.e. number of patients admitted, is still seen in Byelorussia, Romania and Russia. More than 10% of the dialysed patients were treated using peritoneal dialysis, but striking differences between countries were seen, the proportions ranging from 1% in Macedonia to 49% in Estonia.
Nearly half of the dialysed patients were treated with erythropoetin, but large differences between countries were observed, e.g. 15–20% in Yugoslavia and Russia, 30–49% in Romania, Estonia, Croatia, 60–70% in the Czech Republic, Latvija and Poland, 70–90% in Hungary and Lithuania. The proportions of patients receiving EPO showed some correlation to the Gross National Product per capita.
During the last 8 years an increasing number of diabetic patients admitted for RRT was noted in three of the four countries which were analysed in this respect, i.e. Byelorussia, the Czech Republic and Poland, but not in Croatia where the proportion of diabetic patients was stable at 10–12%, although this country has very good dialysis facilities (Figure 1a).
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An increasing number of patients diagnosed as having hypertensive nephropathy was noted in Byelorussia and Poland. In contrast, in the Czech Republic the number of patients with this diagnosis decreased and it was stable in Croatia (Figure 1b
).
There was a remarkable change in the average age of dialysed patients. The number of patients who were more than 65 years of age increased in all of the four countries analysed in this respect despite the different levels of development of dialysis facilities (Table 2). This was most pronounced in the Czech Republic and in Croatia where nearly half and a quarter of dialysed patients, respectively, were in this age bracket.
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Discussion
The above data confirm the dramatic development of RRT in CEE. In comparison to our previous report [1] we now include data from Russia and the former satellites of the Soviet Union, i.e. Byelorussia and Estonia, which have become available for the first time. In these countries, renal care for ESRD patients is still problematic, although it is of note that within Russia the availability of RRT is not uniform. In the regions of Moscow and St. Petersburg, respectively, the availability of dialysis and renal transplantation is satisfactory, but in rural areas the chances of a patient with ESRD to obtain access to any type of RRT are poor. On the other hand, substantial progress has been achieved within the space of a few years in the Baltic countries, i.e. Estonia, Latvija and Lithuania as well as in Romania and Poland [8,9].
It is striking that in many countries, e.g. Slovakia, Bulgaria, Romania, Yugoslavia, Slovenia or Macedonia, renal transplantation is still neglected, although in the long run this treatment modality is much cheaper than any form of dialysis — a point of note in this economically underdeveloped part of the world.
This is the first report giving information on the incidence, i.e. patients admitted with end-stage renal failure, in the CEE region. The average incidence (72 pmp) is far lower than figures reported from Japan [10], the United States [11] or Germany [12], but it is close to the figures reported from Australia and New Zealand [13] or Great Britain [14]. In six countries of the CEE region, the incidence was above 100 pmp and in a further six countries it was above 50 pmp.
In the majority of the countries peritoneal dialysis as a treatment modality has become available only during the last few years. For example, in Macedonia the first CAPD treatment of young children was performed in 1997. Actually, in the region no less than 10% of ESRD patients are treated using this modality. The development of CAPD was particularly dramatic in the Baltic countries, and in Romania and Poland [15]. On the other hand, the use of this method decreased during the last 3 years in Hungary and in Slovakia, possibly reflecting a negative impact of privatization in the dialysis sector in these countries.
Erythropoetin is important for the outcome and quality of life in dialysed patients. This medication is available for nearly half of the ESRD patients in the CEE region [16], the availability of erythropoetin is less in CEE countries with less developed economies.
A burning issue is how countries of the CEE region which have RRT programmes in the stage of development will be able to cope with the rising number of patients with diabetes and hypertensive nephropathy [17–21]. As illustrated in Figure 1, despite differing levels of RRT availability, the number of patients with ESRD and diabetes as a co-morbid condition is still increasing in the majority of CEE countries. Such increase was most dramatic in the Czech Republic where diabetic patients currently account for 31% of patients on dialysis. The majority of these patients suffer from type II diabetes and 58% of them are older than 50 years [4].
In Poland the absolute number of diabetic patients on dialysis increased by a factor of 4 during the past 6 years [22]. Currently close to 12% of all patients on maintenance haemodialysis have diabetes and diabetic patients account for 17% of newly accepted patients [5]. The ratio of type 1 and type 2 diabetes is 1:1. Even in countries with lower rates of acceptance, e.g. Byelorussia or Romania, a sharp increase has been noted. It remains to be examined why in some countries with well-developed RRT systems, e.g. Croatia, Yugoslavia, Slovenia, Macedonia, Slovakia and Hungary, the proportion of diabetic patients amongst the dialysed patients has remained relatively stable in the past few years. This is particularly remarkable, since the number of diabetic patients in these regions is increasing [19]. The number of patients admitted with the diagnosis of hypertensive nephropathy is also increasing in some but not all countries in the CEE region. We are aware of the potential pitfalls of this diagnosis. It is remarkable that in countries with well-developed renal services, e.g. the Czech Republic or Croatia, only 3–4% of the dialysed patients were diagnosed as having hypertensive nephropathy. In the majority of Western European countries approximately 27–28% of dialysed patients are diagnosed as having hypertensive nephropathy.
In parallel with observations in Western Europe [23] and the USA [24] a dramatic increase of elderly patients has been observed in the CEE region and this is most pronounced in the Czech Republic where no less than approximately 50% of patients are above age 65 years and nearly 60% above 60 years [4]. The figures may be artifactually high, however, because of the high transplantation activity in the Czech Republic, since young patients are transplanted preferentially. To a lesser extent, however, an increase of elderly patients is seen throughout the CEE region.
The above results document that the dramatic development in the somewhat heterogeneous CEE countries replicates to differing degrees the epidemiological development which has been noted in Western Europe and in the USA.
Acknowledgments
The authors thank the numerous colleagues in the different countries of central and eastern Europe who participated in the collection of data. We appreciate the encouragement and help provided by Prof. E. Ritz in preparing this communication.
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