Supplemented ERA-EDTA Registry data evaluated the frequency of dialysis, kidney transplantation, and comprehensive conservative management for patients with kidney failure in Europe

Abstract

The aims of this study were to determine the frequency of dialysis and kidney transplantation and to estimate the regularity of comprehensive conservative management (CCM) for patients with kidney failure in Europe. This study uses data from the ERA-EDTA Registry. Additionally, our study included supplemental data from Armenia, Germany, Hungary, Ireland, Kosovo, Luxembourg, Malta, Moldova, Montenegro, Slovenia and additional data from Israel, Italy, Slovakia using other information sources. Through an online survey, responding nephrologists estimated the frequency of CCM (i.e. planned holistic care instead of kidney replacement therapy) in 33 countries. In 2016, the overall incidence of replacement therapy for kidney failure was 132 per million population (pmp), varying from 29 (Ukraine) to 251 pmp (Greece). On 31 December 2016, the overall prevalence of kidney replacement therapy was 985 pmp, ranging from 188 (Ukraine) to 1906 pmp (Portugal). The prevalence of peritoneal dialysis (114 pmp) and home hemodialysis (28 pmp) was highest in Cyprus and Denmark respectively. The kidney transplantation rate was nearly zero in some countries and highest in Spain (64 pmp). In 28 countries with five or more responding nephrologists, the median percentage of candidates for kidney replacement therapy who were offered CCM in 2018 varied between none (Slovakia and Slovenia) and 20% (Finland) whereas the median prevalence of CCM varied between none (Slovenia) and 15% (Hungary). Thus, the substantial differences across Europe in the frequency of kidney replacement therapy and CCM indicate the need for improvement in access to various treatment options for patients with kidney failure. The aims of this study were to determine the frequency of dialysis and kidney transplantation and to estimate the regularity of comprehensive conservative management (CCM) for patients with kidney failure in Europe. This study uses data from the ERA-EDTA Registry. Additionally, our study included supplemental data from Armenia, Germany, Hungary, Ireland, Kosovo, Luxembourg, Malta, Moldova, Montenegro, Slovenia and additional data from Israel, Italy, Slovakia using other information sources. Through an online survey, responding nephrologists estimated the frequency of CCM (i.e. planned holistic care instead of kidney replacement therapy) in 33 countries. In 2016, the overall incidence of replacement therapy for kidney failure was 132 per million population (pmp), varying from 29 (Ukraine) to 251 pmp (Greece). On 31 December 2016, the overall prevalence of kidney replacement therapy was 985 pmp, ranging from 188 (Ukraine) to 1906 pmp (Portugal). The prevalence of peritoneal dialysis (114 pmp) and home hemodialysis (28 pmp) was highest in Cyprus and Denmark respectively. The kidney transplantation rate was nearly zero in some countries and highest in Spain (64 pmp). In 28 countries with five or more responding nephrologists, the median percentage of candidates for kidney replacement therapy who were offered CCM in 2018 varied between none (Slovakia and Slovenia) and 20% (Finland) whereas the median prevalence of CCM varied between none (Slovenia) and 15% (Hungary). Thus, the substantial differences across Europe in the frequency of kidney replacement therapy and CCM indicate the need for improvement in access to various treatment options for patients with kidney failure. Each year, the European Renal Association–European Dialysis and Transplant Association (ERA-EDTA) Registry reports on the frequency and outcomes of dialysis and kidney transplantation (KTx) in Europe.1ERA-EDTA Registry: ERA-EDTA Registry Annual Report 2016. Department of Medical Informatics, Amsterdam UMC, Amsterdam, the Netherlands2018Google Scholar,2Kramer A. Pippias M. Noordzij M. et al.The European Renal Association–European Dialysis and Transplant Association (ERA-EDTA) Registry Annual Report 2015: a summary.Clin Kidney J. 2018; 11: 108-122Crossref PubMed Scopus (166) Google Scholar This report is based on data from national and regional renal registries in Europe and several countries bordering the Mediterranean Sea. However, not all European countries have a renal registry, and, hence, the ERA-EDTA Registry annual report cannot provide a complete overview of kidney replacement therapy (KRT) in Europe. Furthermore, comprehensive conservative management (CCM) has become an alternative to KRT for patients with end-stage kidney disease (ESKD), in particular for those who are older, those who have multiple comorbidities, and those who have an unfavorable prognosis.3Kurella Tamura M. Recognition for conservative care in kidney failure.Am J Kidney Dis. 2016; 68: 671-673Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Up to now, little is known about the frequency of CCM in patients with ESKD in individual European countries.4van de Luijtgaarden M.W. Noordzij M. van Biesen W. et al.Conservative care in Europe-nephrologists' experience with the decision not to start renal replacement therapy.Nephrol Dial Transplant. 2013; 28: 2604-2612Crossref PubMed Scopus (54) Google Scholar,5Bello A.K. Levin A. Lunney M. et al.Global Kidney Health Atlas: A Report by the International Society of Nephrology on the Global Burden of End-Stage Kidney Disease and Capacity for Kidney Replacement Therapy and Conservative Care Across World Countries and Regions.Brussels, Belgium: International Society of Nephrology; 2019Google Scholar In this study, we therefore aimed to determine, more extensively than before, the frequency of dialysis and KTx in Europe, by using ERA-EDTA Registry data supplemented by data from other sources. In addition, we aimed to estimate the frequency of CCM for patients with ESKD in individual European countries based on an online survey among nephrologists. An added value of this study is that now, for the first time, the proportional relationship of all therapeutic options in all European countries can be estimated. Figure 1 shows a map of Europe with the incidence of KRT on day 1 (Figure 1a), prevalence of KRT (Figure 1b), KTx rate (Figure 1c), mean estimated percentage of patients who were offered CCM (Figure 1d), and mean estimated prevalence of CCM (Figure 1e) in all participating countries. In 2016, 97,996 patients in 39 countries commenced KRT for ESKD. Figure 2a demonstrates the incidence of KRT by treatment modality, which was highest in Greece (251 per million population [pmp]), Czech Republic (243 pmp), and Portugal (236 pmp), whereas it was lowest in Ukraine (29 pmp), Russia (59 pmp), and Belarus (62 pmp). For Czech Republic, Poland, Russia, Tunisia (Sfax region), and Slovakia, we were unable to obtain data on preemptive KTx and therefore we used the incidence of dialysis instead. The highest incidence of preemptive KTx was reported by the Netherlands (17 pmp), Turkey (15 pmp), and Norway (12 pmp). Figure 2b displays the incidence of KRT by treatment modality on day 91. The incidence of hemodialysis was highest in Greece (208 pmp), Portugal (199 pmp), and Israel (157 pmp), whereas for peritoneal dialysis (PD), the incidence was highest in Cyprus (41 pmp), Sweden (38 pmp), and Denmark (37 pmp). On 31 December 2016, 690,173 patients in 45 countries received KRT for ESKD. Figure 3 shows the prevalence of KRT by treatment modality. Portugal had the highest prevalence of KRT (1906 pmp), followed by Cyprus (1575 pmp) and Belgium (1286 pmp). The prevalence of center hemodialysis was highest in Portugal (1143 pmp), Greece (979 pmp), and Romania (887 pmp), and that of home hemodialysis (HHD) was highest in Denmark (28 pmp), Finland (25 pmp), and the United Kingdom (20 pmp). In many countries, HHD was not reported or did not exist. The prevalence of PD was highest in Cyprus (114 pmp), Denmark (97 pmp), and Sweden (90 pmp). The prevalence of patients with a functioning kidney transplant was highest in Cyprus (817 pmp), Portugal (693 pmp), and Spain (672 pmp). It was lowest in Ukraine (27 pmp), Serbia (52 pmp), and Armenia (estimated 58 pmp). In 2016, 26,008 KTx procedures were performed in 44 countries. Figure 4 depicts the number of KTx procedures performed by country, demonstrating the highest KTx rates in Spain (64 pmp), the Netherlands (59 pmp), and France (54 pmp). Notably, in Spain, the vast majority of transplants were from deceased donors (57 pmp), whereas in the Netherlands, a small majority of transplants were from living donors (33 pmp). The lowest number of KTx procedures was performed in Montenegro, North Macedonia, and Ukraine (all 3 pmp) and Armenia (2 pmp), whereas none was performed in Luxembourg. Under the umbrella of the European Union “The Effect of Differing Kidney Disease Treatment Modalities and Organ Donation and Transplantation Practices on Health Expenditure and Patient Outcomes” (EDITH) Nephrologist survey, 587 nephrologists from 33 countries estimated the frequency of CCM (i.e., planned holistic care instead of KRT) (Supplementary Table S4). Figure 5a and b shows the estimated median percentages of patients who were offered CCM and the prevalence of CCM in 2018 for countries with at least 5 respondents on the survey. In the remaining 28 countries, the estimated percentage of ESKD patients who were offered CCM varied from 0.0% (Slovakia and Slovenia) to 20.0% (Finland). The estimated prevalence of CCM ranged between 0.0% (Slovenia) and 15.0% (Hungary). In 2016, the overall incidence of KRT in Europe was 132 pmp, reflecting that in this year, 1 in 7584 Europeans (0.013%) started KRT (Table 1). The overall prevalence of KRT was 985 pmp, reflecting that 1 in 1016 Europeans (0.098%) was treated with KRT. The overall number of KTx procedures performed was 38 pmp.Table 1Summary statistics of the incidence and prevalence of KRT for ESKD in European countries by treatment modality and the number of performed KTx procedures by donor source, pmp, in 2016VariableKRTHDPDKTxLD KTxDD KTxIncidence pmp on day 1132109175Incidence pmp on day 9112299175Prevalence pmp on 31 December 201698550252430No. of performed kidney transplants pmp38830DD, deceased donor; ESKD, end-stage kidney disease; HD, hemodialysis; KRT, kidney replacement therapy; KTx, kidney transplantation; LD, living donor; PD, peritoneal dialysis; pmp, per million population.Categories may not add up because of missing values or rounding off. The summary statistics are based on data from the following countries: Albania, Austria, Belarus, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Denmark, Estonia, Finland, France, Georgia, Greece, Iceland, Italy, Latvia, Lithuania, the Netherlands, North Macedonia, Norway, Portugal, Romania, Serbia, Spain, Sweden, Switzerland, Ukraine, and United Kingdom. Open table in a new tab DD, deceased donor; ESKD, end-stage kidney disease; HD, hemodialysis; KRT, kidney replacement therapy; KTx, kidney transplantation; LD, living donor; PD, peritoneal dialysis; pmp, per million population. Categories may not add up because of missing values or rounding off. The summary statistics are based on data from the following countries: Albania, Austria, Belarus, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Denmark, Estonia, Finland, France, Georgia, Greece, Iceland, Italy, Latvia, Lithuania, the Netherlands, North Macedonia, Norway, Portugal, Romania, Serbia, Spain, Sweden, Switzerland, Ukraine, and United Kingdom. Supplementary Table S5 provides general population data by country. Supplementary Tables S1–S4 present all values corresponding to Figure 2, Figure 3, Figure 4, Figure 5, respectively. Supplementary Tables S1 and S2 show country-specific data on center hemodialysis, HHD, PD, as well as living and deceased donor KTx procedures separately. Supplementary Table S4 shows data of all countries on both the estimated mean percentage (SD) and median percentage (interquartile range) of patients who were offered CCM and on the prevalence of CCM. The current study presents the most extensive data on the frequency of KRT for ESKD in Europe so far. In addition to ERA-EDTA Registry data, data on 10 more countries (Armenia, Germany, Hungary, Ireland, Kosovo, Luxembourg, Malta, Moldova, Montenegro, and Slovenia) were included. This implies that, with the exception of some small countries (Andorra, Liechtenstein, Monaco, San Marino, and Vatican City), all nations in Europe were represented. Moreover, this study estimated the frequency of CCM for ESKD in 33 European countries. Our findings show that the overall incidence of KRT in Europe was 132 pmp in 2016. This is substantially lower than the incidence of KRT in the United States (378 pmp), Japan (296 pmp), and Canada (200 pmp) but higher than the incidence in Australia and New Zealand (117 and 119 pmp, respectively).6US Renal Data System2018 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2018Google Scholar Across the world, the KRT incidence has been reported to vary nearly 22-fold, ranging from 22 pmp in South Africa to 493 pmp in Taiwan.6US Renal Data System2018 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2018Google Scholar Of note, this difference may even be higher as for some countries without KRT data, the incidence may be low or KRT may not exist at all. Our results show that in Europe, the KRT incidence varied nearly 9-fold, ranging from 29 pmp in Ukraine to 251 pmp in Greece. According to our results, the vast majority of European patients started on hemodialysis, whereas only about 4% underwent preemptive KTx, which is slightly higher than in the United States (2.8%).6US Renal Data System2018 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2018Google Scholar Trend analysis of data from 14 countries from the ERA-EDTA Registry database suggests a slight increase in the crude incidence of KRT in Europe over the period 2012 to 2016.7ERA-EDTA RegistrySlides summarizing annual report 2016.https://era-edta-reg.org/files/annualreports/ppt/Slides%20summarizing%20AR2016_20180814_afb.pptxDate accessed: October 21, 2020Google Scholar Several factors may contribute to the international differences in KRT incidence. First, they may be due to variation in the prevalence of chronic kidney disease (CKD) stages 3 to 5 in the general population,8Bruck K. Stel V.S. Gambaro G. et al.CKD prevalence varies across the European general population.J Am Soc Nephrol. 2016; 27: 2135-2147Crossref PubMed Scopus (357) Google Scholar which, in turn, may be explained by differences in the prevalence of risk factors for CKD, such as diabetes mellitus.9Stel V.S. Bruck K. Fraser S. et al.International differences in chronic kidney disease prevalence: a key public health and epidemiologic research issue.Nephrol Dial Transplant. 2017; 32: ii129-ii135Crossref PubMed Scopus (32) Google Scholar Second, international differences may exist in the progression of CKD and in mortality of patients with CKD (e.g., because of differences in genetic predisposition or primary and secondary preventive measures).10Bruck K. Jager K.J. Zoccali C. et al.Different rates of progression and mortality in patients with chronic kidney disease at outpatient nephrology clinics across Europe.Kidney Int. 2018; 93: 1432-1441Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar Third, the access to KRT may vary because of differences in patient selection, the of KRT and of ESKD treatment options (e.g., a higher incidence of CCM may in a lower incidence of A. et al.Global variation in renal replacement therapy for end-stage renal Dial Transplant. PubMed Scopus Google van S. Noordzij M. et replacement therapy for the the need for a Nephrol. 2018; PubMed Scopus Google K.J. Stel V.S. et al.The of kidney disease treatment and and transplantation on health and patient Dial Transplant. 2018; PubMed Scopus Google Scholar such as health care are to have a on the access to A. et al.Global variation in renal replacement therapy for end-stage renal Dial Transplant. PubMed Scopus Google A. Stel V.S. Jager K.J. et for of European kidney dialysis and of kidney replacement Dial Transplant. PubMed Scopus Google Scholar In 2016, the overall prevalence of KRT in Europe was 985 This is lower than the reported prevalence in Japan pmp), the United States pmp), and Canada pmp) and to the prevalence in Australia and New Zealand and pmp, respectively).6US Renal Data System2018 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2018Google Scholar Across the world, KRT prevalence varied nearly ranging from pmp in to pmp in Taiwan.6US Renal Data System2018 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2018Google Scholar it is that for several countries, the KRT prevalence is not known or KRT may not exist. Our findings show that in Europe, the KRT prevalence varied ranging from 188 pmp in Ukraine to 1906 pmp in Portugal in 2016. than of all patients in Europe and in the United were on whereas in and all patients were on dialysis and KTx rates were Renal Data System2018 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2018Google Scholar in some European countries with a KRT prevalence (e.g., Germany, Greece, and the vast majority of patients were on dialysis the KTx rates were According to data from the ERA-EDTA has been a increase in the prevalence of KRT in Europe between 2012 and 2016.7ERA-EDTA RegistrySlides summarizing annual report 2016.https://era-edta-reg.org/files/annualreports/ppt/Slides%20summarizing%20AR2016_20180814_afb.pptxDate accessed: October 21, 2020Google Scholar hemodialysis is by the most used dialysis modality in Europe, several demonstrating differences in patient M. Jager K.J. between and peritoneal Dial Transplant. 27: PubMed Scopus Google Scholar and of The of dialysis on the of of patients with end-stage renal a 2016; PubMed Scopus Google Biesen W. et modality in patients with end-stage renal a of the Dial Transplant. 2017; 32: Google Scholar between hemodialysis and PD, and PD be a therapy with hemodialysis in most M. G. et analysis of renal replacement therapy in Dial Transplant. PubMed Scopus Google van J. et of patients on renal replacement analysis of health Scopus Google Scholar to PD is in some and European A.K. Levin A. Lunney M. et al.Global Kidney Health Atlas: A Report by the International Society of Nephrology on the Global Burden of End-Stage Kidney Disease and Capacity for Kidney Replacement Therapy and Conservative Care Across World Countries and Regions.Brussels, Belgium: International Society of Nephrology; 2019Google Scholar This may be due to hemodialysis dialysis in countries as well as to the of PD with the of The number of patients using HHD in Europe is and this treatment not even exist in many countries. HHD was most in New Zealand of dialysis Renal Data System2018 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2018Google Scholar in only 3 in the and of the dialysis population is on HHD or Renal Data System2018 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2018Google Scholar KTx is with and of and lower with M. G. et analysis of renal replacement therapy in Dial Transplant. PubMed Scopus Google M. G. et kidney transplantation with dialysis in J Transplant. 11: Full Text Full Text PDF PubMed Scopus Google et of mortality in all patients on patients on dialysis and of a first J PubMed Scopus Google M. A. et and of of in chronic kidney disease Scopus Google Scholar However, patients with ESKD who are for KTx may not a kidney because of such as of or or and et of in European Int. PubMed Scopus Google A. C. et in results from an online Int. 2013; PubMed Scopus Google J. et kidney to kidney from a J Am Soc Nephrol. PubMed Scopus Google from PubMed Scopus Google Scholar On the other a of patients with ESKD may be for KTx, due for In such dialysis or CCM may be more A variation in KTx rates between the European countries, ranging from zero in some countries to a of pmp in Europe, the vast majority of are from deceased donors whereas this is lower on Donation and accessed: Scholar Of note, in a in with the highest KTx rate pmp) in the world, of the from living Renal Data System2018 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States. National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2018Google Scholar the of living donor deceased donor varied across the European countries. In Spain, the vast majority of are from deceased because of the of various such as an of donors to the transplant for and to of donor et Spain deceased donors per million J Transplant. 2017; Full Text Full Text PDF PubMed Scopus Google Scholar in the Netherlands, with a KTx more than of are from living This may be to several such as about living a in of living donor and a of from for the living on Donation Under the European Kidney on Organ Donation and Transplantation accessed: 4, 2020Google Scholar The in which is a donor they not to at the of is as to the deceased donor However, a did not a difference in the and deceased donor KTx rates between countries with and A. A. of and transplantation rates between and Int. Full Text Full Text PDF PubMed Scopus Google Scholar little information on the frequency of CCM in individual European countries. In the United CCM was in all renal in with a variation in the number of patients between the S. et al.Conservative care for in the United a national J Am Soc Nephrol. PubMed Scopus Google Scholar In a study from the CCM was to of ESKD A. et conservative therapy in chronic kidney PubMed Google Scholar In from the ERA-EDTA Registry that, in European countries, CCM was to 15% of the ESKD patients on de Luijtgaarden M.W. Noordzij M. van Biesen W. et al.Conservative care in Europe-nephrologists' experience with the decision not to start renal replacement therapy.Nephrol Dial Transplant. 2013; 28: 2604-2612Crossref PubMed Scopus (54) Google Scholar In the current we of this ERA-EDTA Registry study using the Nephrologist survey, but more countries and per individual country. In with the Global Kidney Health we that CCM was in both and A.K. Levin A. Lunney M. et al.Global Kidney Health Atlas: A Report by the International Society of Nephrology on the Global Burden of End-Stage Kidney Disease and Capacity for Kidney Replacement Therapy and Conservative Care Across World Countries and Regions.Brussels, Belgium: International Society of Nephrology; 2019Google Scholar Our findings international differences in the frequency of with several an estimated prevalence of CCM of North Macedonia, Serbia, and Slovenia) and an estimated prevalence of CCM of and from such international differences may be by variation in primary care and the nephrology are to about CCM as an treatment for patients who are not to from KRT. to be and the of the the of CCM in countries. In addition, nephrologists may experience such as and about is to be a with the patient and Stel V.S. et reported by nephrologists renal replacement therapy or comprehensive conservative management to end-stage kidney disease a Dial Transplant. PubMed Scopus Google Scholar The of this study are the of Europe and the of information on the frequency of KRT, center hemodialysis, HHD, PD, and KTx from living and deceased donors as well as on CCM. This study has several First, some data (e.g., on the of kidney were for some countries. Second, for countries, the frequency of KRT was estimated or from or Furthermore, we estimated the prevalence of patients living with a functioning kidney transplant for 5 countries with The frequency of CCM was estimated by several nephrologists per based on a survey, and the may not be to all nephrologists in the country. did not respondents and therefore we not which received the survey and they or we were not to a rate or the of with those of Third, we the of CCM to the we cannot that nephrologists may have CCM as conservative from Levin A. et summary of the on Care in Kidney a to Int. Full Text Full Text PDF PubMed Scopus Google Scholar of other may between countries (e.g., center hemodialysis can and some may not be (e.g., Of note, the number of with ESKD may vary across countries. This extensive overview demonstrates differences in the frequency of dialysis and KTx across the European countries. In addition, for the first time, it is that the frequency of CCM between countries.

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