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NDT Advance Access originally published online on November 9, 2005
Nephrology Dialysis Transplantation 2006 21(1):4-10; doi:10.1093/ndt/gfi251
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© The Author [2005]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Editorial Comment

Highlights of the epidemiology of renal replacement therapy in Central and Eastern Europe

Boleslaw Rutkowski

Department of Nephrology, Transplantology and Internal Medicine, Medical University, Gdansk, Poland

Correspondence and offprint requests to: Professor Boleslaw Rutkowski, Department of Nephrology, Transplantology and Internal Medicine, Medical University, Debinki 7, 80-211 Gdansk, Poland. Email: bolo{at}amg.gda.pl



   Abstract
Top
 Abstract
Introduction
 Subjects and methods
 Results and comments
 Summary and conclusions
 References
 
Background. In the past 15 years, dramatic political and economic changes have occurred in Central and Eastern Europe (CEE) which also had a positive impact on the availability of renal replacement therapy. The aim of the present study was to analyse the progress achieved in the new millennium.

Methods. Data from 18 CEE countries collected during two independent surveys (1999 and 2002) were validated using information from national and ERA-EDTA registries, and analysed.

Results. The data collected from 18 CEE countries clearly document further development and improvement of renal replacement therapy in this region of Europe. In 63% of countries, the incidence rate had become comparable with that observed in more developed European countries. The two main modalities of dialysis, i.e. haemodialysis and peritoneal dialysis, are used. The frequency of the use of PD varies between 0.5% and nearly 37%. Privatization of dialysis units has started in 18 CEE countries. Currently between 2.5% (Russia) and 90% (Hungary) of patients are treated in non-public centres. Renal transplantation is quite well developed in half of the CEE states. In the states on the territory of the former Soviet Union, substantial progress in renal replacement therapy was achieved in the Baltic states, but the development in Byelorussia and Russia is still unsatisfactory.

Conclusion. The availability and outcome of renal replacement therapy in the majority of states in CEE have become comparable with what is seen in more developed Western Europe. Nevertheless, large differences exist between individual countries. In particular, definite improvement is urgent in Byelorussia and Russia.

Keywords: Central and Eastern Europe; epidemiology; progress; renal replacement therapy



   Introduction
Top
 Abstract
 Introduction
Subjects and methods
 Results and comments
 Summary and conclusions
 References
 
Central and Eastern Europe (CEE) consists of 18 countries with >330 million inhabitants. Several issues concerning renal replacement therapy in these countries had been presented and discussed in previous publications [1–8]. Together with colleagues from CEE countries, we had documented the development of dialysis and renal transplantation in this region after the implosion of the Soviet Union. During the inefficient ‘socialist’ system, renal replacement therapy was underdeveloped in the majority of CEE countries [2,4]. This situation was mainly caused by economic constraints and insufficient health care budgets [8]. More than 15 years ago, political and economic changes revolutionized the conditions including the health care systems in this part of Europe. Several new independent countries appeared on the map of our continent. Currently some of them have become members of the European Union. Step by step with the change of health care systems, the availability of renal replacement therapy has increased substantially [9,10].

The present communication reports on the progress of renal replacement therapy achieved during the 5 years of the new millennium, with special attention to the countries on the territory of the former Soviet Union.



   Subjects and methods
Top
 Abstract
 Introduction
 Subjects and methods
Results and comments
 Summary and conclusions
 References
 
Most of the data were collected from independent surveys performed in 1999 and 2002. Special questionnaires were completed by the members of the CEE Advisory Board in Chronic Renal Failure. They used data they had collected from individual renal units or that had been obtained from the National Registries. Some of the data were validated using recent publications prepared by the National Registries [11–17] or information obtained from the ERA-EDTA Registry reports [18]. For the first time, data from 16 countries: Bosnia and Hercegovina, Bulgaria, Byelorussia, Croatia, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Macedonia, Poland, Romania, Russia, Serbia and Montenegro, and Slovenia were subjected to more detailed analysis. Unfortunately, reliable data from Albania, Moldova and the Ukraine are not available despite several efforts to collect basic numbers.



   Results and comments
Top
 Abstract
 Introduction
 Subjects and methods
 Results and comments
Summary and conclusions
 References
 
Progress in dialysis therapy
The data presented in Table 1 clearly document that during the 5 year period, two countries, Romania and Lithuania, have become absolute leaders with respect to progress in dialysis therapy, concerning both prevalence and incidence. Furthermore, in Estonia and Poland, the situation of patients with end-stage renal disease (ESRD) has greatly improved. Progress was much slower in Byelorussia and Russia. In both countries, the incidence and prevalence rates are still very low. Traditionally the situation with respect to dialysis has been best in former Yugoslavian countries (Croatia, Macedonia, Serbia and Montenegro, and Slovenia) and this was still true at the beginning of political changes. Not surprisingly, therefore, further progress achieved in these countries during the period covered by this report was rather low [8,11]. Similarly, in countries with well developed dialysis systems such as the Czech Republic, Hungary or Slovakia, further progress was also moderate. The development of dialysis in Bulgaria was surprisingly low and unsatisfactory, with an average increase in the prevalence and incidence rates of 1%.


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  		Table 1. Development of dialysis treatment in Central and Eastern Europe during the period 1998–2002

 
This part of the present report can be summarized by saying that despite much progress achieved in this part of Europe, the development of dialysis facilities is too slow in some countries, especially in Russia and other countries on the territory of the former Soviet Union. Nevertheless, even in this group of countries, substantial achievements were noted in the Baltic states (Estonia, Latvia and Lithuania), and Lithuania has become a leader in rapidly developing dialysis facilities. Presumably faster economic development and substantial modifications in the health care system account for such improved results, but we should not neglect the dedicated involvement of the nephrological community which was also a decisive factor [19]. The latter is also true for the development of dialysis in Poland [10,20] and recently also in Romania [17]. In contrast, the results achieved in Byelorussia are far from satisfactory, but even in this economically disadvantaged country some progress has been achieved. The situation concerning dialysis availability is least satisfactory in Russia. In our previous publications, we reported huge differences between the different regions of Russia [8]. The situation is much better in metropolitan areas such as Moscow or St Petersburg than in rural areas. Accordingly, the average values for prevalence and incidence rates are very low and are more comparable with countries such as China or India than with European countries [9,22–24]. Russian nephrologists are trying to do their best, as shown in Table 2, but without a special programme supported by the national health care authorities, it will be very difficult to achieve real substantial progress.


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  		Table 2. Utilization of the dialysis modalities in Central and Eastern European countries

 
One satisfactory aspect is the fact that among the CEE countries, the incidence rates in 10 out of 16 (63%) countries have crossed the magical barrier of 100 per million population (p.m.p.). It is a real achievement which documents that dialysis treatment has become available to all patients with ESRD as is the case in the more developed, European countries [18].

Dialysis modalities
Haemodialysis (HD) is the modality which is used in >90% of patients dialysed in the vast majority of CEE countries (Table 2). Only in Estonia, Latvia, Romania and to some extent in Poland is peritoneal dialysis (PD) more popular. Looking at the present state of PD in our region, one must be aware of the fact that at the beginning of political changes, this modality was used only in a few countries and a very limited number of patients [2,3]. This was mainly due to economic reasons because, in the strange ‘socialist’ system, PD was much more expensive than HD [16,20,25–27]. Thus, PD was really introduced in CEE during the last 10–15 years. Nevertheless, in the majority of countries in CEE, step by step a PD system has been built up, including home delivery and creation of specialistic centres [8]. Furthermore, use of modern techniques such as automated peritoneal dialysis (APD) and individualization of PD fluids prescription has become more and more common. The best example is Poland where >40% of PD patients are treated using different modes of APD. Furthermore, icodextrin- or even biocarbonate-based fluids are used quite commonly [3]. Among the post-Soviet countries, it is only in the Baltic states that a PD system has been well developed: in Estonia and Latvia. PD is used in 36.7 and 29.9% of dialysed patients, respectively. In contrast, in Byelorussia and Russia, the utilization of PD is still quite low and the little progress that has been achieved during the past 5 years is unsatisfactory (Tables 2 and 3). On the other hand, in countries with more developed dialysis systems such as Hungary or Slovakia, even a decreased use of PD has occurred during the period covered by this report. This phenomenon has appeared in parallel with the privatization of HD units (Figure 1) and this relationship is causal [28]. A similar situation had been reported in the past from other European countries, from the USA and from Canada [26,27,29].


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  		Table 3. Development of different renal replacament therapy modalities in Russia during the period 1998–2002

 


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  		Fig. 1. Percentage of patients treated in private (non-public) haemodialysis units in Central and Eastern European countries: dotted boxes 2001 vs hatched boxes 2003; see text.

 
Privatization of dialysis facilities
Political and economic changes in the countries of CEE have made possible the involvement of private capital in the health care system. HD units were privatized quite early in Hungary [14], and in other CEE countries HD units were privatized during the past 3–5 years. Data presented in Figure 1 show that currently in three countries (Hungary, Slovakia and Lithuania), >50% of patients are dialysed in private (non-public) HD units. In five countries (Czech Republic, Poland, Estonia, Slovenia and Latvia), between 15 and 25% of patients are treated in such facilities. In three countries (Serbia, Bosnia and Russia), only a limited number of units has been privatized. In Figure 1, a few countries are mentioned where privatization of this health care sector has not yet started at all. The one exception is Romania: in 2004, privatization was implemented quickly and at the end of the year 17% of patients were dialysed in private HD units. Bulgarian nephrologists are ready to start privatization, but this first requires some legal and economic changes [16]. In the vast majority of countries, privatization of HD units is in the hands of internationally recognized medical companies such as Fresenius Medical Care, Gambro Healthcare or Braun (Avitum), but there are also other players in the dialysis market representing private capital [28]. Among the countries on the territory of the former Soviet Union, once again the Baltic countries are leaders in privatization. To our knowledge, only two private HD centres are currently operating in Russia, and in Byelorussia the current political regime tries to promote any kind of privatization in the health care sector. We emphasize that in many CEE countries, privatization of HD units provides the opportunity to obtain new investment and introduce modern techniques. Because of inadequate public resources, such progress would otherwise be impossible. Furthermore, privatization permits more rational use of the money reimbursed to the units: in underfunded public hospitals, such money is often used to cover expenditure unrelated to dialysis [28].

Outcome of dialysis treatment
Undoubtedly the best outcome for a dialysed patient is successful renal transplantation. As shown in Figure 2, transplantation activity differs markedly in CEE countries. The highest absolute number of renal transplantations per year is performed in Poland, Russia and the Czech Republic. Nevertheless, if one considers the percentage of patients living with a functioning graft among the entire cohort of patients on renal replacement therapy, the best results are achieved in Estonia, Latvia and the Czech Republic, and figures are still satisfactory in Poland and Hungary. The frequency is lowest in former Yugoslavian countries such as Macedonia, Bosnia, Serbia or Croatia. After the disintegration of former Yugoslavia and the following political upheaval on the Balkan peninsula, renal transplantation apparently ceased completely. Today, step by step, a new system of renal transplantation is being developed in those countries. It is also noteworthy that the high prevalence of dialysed patients in the countries located in this part of CEE is caused mainly by the low transplantation activity. A low transplantation activity is also noted in Bulgaria where a real crisis of renal transplantation was observed during the 1990s. Fortunately, at the end of the last century, Bulgarian nephrologists and transplantologists started to rebuild a renal transplantation system in their country. It is worth mentioning that the donation of renal grafts from living related donors is very well organized in Bulgaria (e.g. in 2001, transplantations from living donors accounted for 40% of renal transplantations) [16]. Among the post-Soviet countries, once again it is the Baltic countries, especially Estonia and Latvia, where the frequency of transplantation is highest. In Byelorussia, only a few renal transplations are performed. In Russia, the transplant centres in Moscow and St Petersburg are thriving; nevertheless, this procedure is too centralized and the activity of regional centres is very low or non-existent.



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  		Fig. 2. Renal transplantation (RTx) in Central and Eastern European countries: (a) number of RTx in 2002; (b) percentage of renal replacement modalities in 2002.

 
Measures of dialysis outcome are actuarial survival and mortality rates. Survival measures are not available in the majority of CEE countries because data collection in their National Renal Registries is based mainly on the centre questionnaires [19,21]. In this situation, only crude annual mortality rates are available (Figure 3). In the vast majority of countries, the rate varies between 12.5 and 15%. Only in the Czech Republic is the mortality rather high: most probably this is the result of the high age of the dialysis population (in 2002, 60% of dialysed patients were >60 years of age) and the high prevalence of diabetes (in 2002, 37% of dialysed patients were diabetics) [13]. The increase in the proportion of elderly and diabetics among ESRD patients is observed not only in CEE, but worldwide [8,10,30]. The low mortality in Russia is mainly the result of the insufficient availability of dialysis in this country resulting in patient selection so that dialysed patients are much younger and the percentage of diabetics and patients with serious co-morbidities is significantly lower. The same phenomenon was seen in other CEE countries several years ago [2–4]. The range of mortality observed in CEE is comparable with what is seen in other European countries [18] and lower than what is reported from the USA [31].



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  		Fig. 3. Annual crude mortality among patients dialysed in Central and Eastern European countries.

 


   Summary and conclusions
Top
 Abstract
 Introduction
 Subjects and methods
 Results and comments
 Summary and conclusions
References
 
In the vast majority of CEE countries, renal replacement therapy today is much better developed than at the beginning of the political and economic changes in this region after the implosion of the Soviet Union. Dialysis therapy is available for all ESRD patients in 63%, i.e. 10 out of 16 countries in CEE. The two main dialysis modalities, i.e. HD and PD, are used in all countries of the region, but utilization of PD varies from 0.5 to 36.9%. Recently, privatization of dialysis units is more and more common in this part of the world. Renal transplantation is well developed in half of the CEE countries, but is still underdeveloped mainly in former Yugoslavian countries, Bulgaria and Byelorussia. Crude mortality rates in CEE countries are comparable with those in other European countries. With respect to renal replacement therapy in countries on the territory of the former Soviet Union, real progress in dialysis and renal transplantation was achieved by the three Baltic countries, whereas the current state in Byelorussia and Russia is still unsatisfactory and requires major changes of the system of renal care. Further efforts are necessary to obtain information on renal replacement therapy in Albania, Moldova and the Ukraine.



   Acknowledgments
 
I wish to express my gratitude to all colleagues from the Central and Eastern European Advisory Board for Chronic Renal Failure and members of National Renal Registries for delivering data which enabled preparation of this paper.

Conflict of interest statement. None declared.



   References
Top
 Abstract
 Introduction
 Subjects and methods
 Results and comments
 Summary and conclusions
 References
 

  1. Rutkowski B, Wielgosz A, Puka J. Ambitious programme seeks to improve dialysis therapy in Poland. Nephrol News Issues Eur 1994; 2: 24–27
  2. Rutkowski B, Ciocalteu A, Djukanovic L et al. Evolution of renal replacement therapy in central and eastern Europe 7 years after political and economical liberation. Nephrol Dial Transplant 1997; 12: 860–864
  3. Rutkowski B, Puka J, Lao M et al. Renal replacement therapy in an era of socioeconomic changes—report from the Polish Registry. Nephrol Dial Transplant 1997; 12: 1105–1108[Abstract/Free Full Text]
  4. Rutkowski B, Ciocalteu A, Djukanovic L et al. Treatment of end-stage renal disease in Central and Eastern Europe. Overview of current status and future needs. Artif Organs 1998; 22: 187–191[Medline]
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  13. Lachmanova J, on behalf of the Czech nephrological community. Annual Statistics of Dialysis Therapy in Czech Republic—2002. Janssen Cilag CR, Prague, 2003
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Received for publication: 13. 4.05
Accepted in revised form: 9.10.05


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