The health system in Chile: the nephrologist perspective

Chile is a country with 17 million inhabitants, 13% of them living in rural areas, and with a per capita income of approximately US $14,500. Three percent of national income is assigned to the health budget, with a mixed public and private system, with guaranteed medical benefits from the state to cover chronic kidney disease (CKD) and renal replacement therapy (RRT). Hemodialysis has reached in 2009 a prevalence of 857 patients per million population (pmp). Peritoneal dialysis is less developed, with a prevalence of 40 patients pmp. Both therapies show good quality indexes with a patient mortality rate close to 12% per year. A centralized national renal transplantation program registered 5,949 renal transplants performed up to 2009. Renal survival at 5 years is 86% for living and 76% for cadaveric donor transplants. Organ donation is relatively low with 7.1 cadaveric donors pmp in 2009, despite legal and educational strategies to increase it. Although the country demonstrates one of the highest standards for RRT indexes in Latin America, the proportion of resources invested makes it necessary to improve early diagnosis and renal prevention policies to avoid having the growing incidence of CKD constrain the national health budget.     

The Latin American Dialysis and Renal Transplantation Registry Annual Report 2002

Latin America is a conglomerate of adjacent countries having in common a Latin extraction and language (Spanish or Portuguese) and exhibiting extreme variations in socioeconomic status. The Latin American Society of Nephrology and Hypertension Dialysis and Renal Transplantation Registry was created in 1991. Annual data are sent by local societies in 3 forms: patient, center, and country. The prevalence of renal replacement therapy (RRT) (all modalities) increased from 119 patients per million population (pmp) in 1991 to 349 pmp in 2001; the acceptance rate was 91.7 pmp in 2001. Dialysis prevalence was 277 pmp; hemodialysis was the predominant modality, except in Mexico (86% on peritoneal dialysis). The highest dialysis prevalence and acceptance rates were reported by Puerto Rico, Uruguay, and Chile. Among incident patients, diabetic nephropathy (33%) and nephroangioesclerosis (32%) were the primary causes; 38% were older than 65 years old. Renal transplants increased from 3.7 pmp in 1987 to 13.7 pmp in 2001. In 2003, 6357 transplants were performed (55% living donor); the cumulative number performed since 1987 reached 55,947. Prevalence and incidence are low because not all patients with end-stage renal disease have access to RRT because of restricted availability, difficulties in referral, and inequities in coverage. The annual increase in the number of patients on RRT (8%-10%) is higher, proportionally, than the annual growth of the Latin American population in general (1.5%). Efforts must be focused on prevention and treatment of chronic kidney disease, especially in diabetic and older patients, and in implementing better organ donation programs to improve the pool of cadaveric donors.     

Systolic and diastolic function in renal replacement therapy: a cross-sectional study

BACKGROUND: Heart disease is the main cause of death among uremic patients (pts). Our study aimed to assess left ventricular (LV) systolic and diastolic function in all of our pts on renal replacement therapy (RRT), investigating any differences between hemodialysis (HD), peritoneal dialysis (PD) and transplantation (TX) pts. METHODS: All pts on RRT at our nephrology unit were enrolled in the study and evaluated once over a period of 6 months: 125 pts were studied: 61 pts on HD, 30 pts on PD and 34 TX pts. Systolic and diastolic function indexes were compared between HD, PD and TX pts. All comparisons were corrected for the effects of age, gender and time on treatment. RESULTS: HD pts suffered from worse systolic function, with a lower mean fractional shortening and ejection fraction (EF), than TX pts. Twenty percent of HD pts had an EF value <55%. PD pts showed worse diastolic function than TX pts and >80% of them suffered from pathological diastolic indexes. The proportion of hypertensive pts was TX 88.2%, PD 86.7% and HD 50.8%. The percentage of pts with LV hypertrophy (LVH) was TX 55.9%, PD 53.3% and HD 36.1%. CONCLUSIONS: TX pts had better systolic and diastolic function than HD and PD pts, despite having more hypertension and LVH.     

Renal replacement therapy in the Canary Islands: demographic and survival analysis

BACKGROUND: The continuous increase in the number of patients on renal replacement therapy (RRT) has heightened the importance of renal patient registries to respond to the demand for data on the state of health, quality and cost of care provided for these patients. Our aim was to analyze the epidemiological profile of this population in the Canary Islands. METHODS: All patients on RRT between January 1999 and December 2003 were considered in this analysis. The information was obtained from the database of the Canary Registry of Renal Patients. RESULTS: We observed a continuous increase in incidence throughout the study period (from 138 per million population (pmp) in 1999 to 160 pmp in 2003), being more evident in patients >65 yrs. Prevalence followed a similar course, increasing from 875 to 972 pmp, being especially evident in the 65-74 yr age group. An alarming finding was the high incidence (43.5%) and prevalence (37.5%) of diabetic nephropathy. While the proportion of hemodialysis (HD) or transplant patients increased, that of peritoneal dialysis (PD) remained low and stable (prevalence of 5% in 2003). Almost half the RRT patients had functioning grafts, with a notably high rate of 58 transplants pmp in 2003, and a prevalence of 425 pmp. Age (hazard ratio (HR) [95% confidence interval (95% CI)] 1.04 [1.03-1.05]; p < 0.001) and diabetic nephropathy (1.47 [1.19-1.82]; p < 0.001) were independently associated with mortality in dialysis patients. Those returning to dialysis after graft loss had a 69% greater risk of death than incident dialysis patients (1.69 [1.06-2.69]; p = 0.026). Cardiovascular events were the main cause of death in all dialysis modalities. Patient death was the main cause of graft loss. CONCLUSIONS: The most outstanding finding was the high incidence and prevalence of patients on RRT, mainly due to diabetic nephropathy. Renal transplant rates were among the highest reported in renal patient registries.     

Malaysian Dialysis and Transplant Registry Report

SUMMARY: This report summarizes data for dialysis and transplant patients up to the end of 1995. We estimate coverage to be about 30% of dialysis patients and near complete ascertainment of transplant patients. On the 31 December 1995, there were 2224 patients on renal replacement therapy (RRT), comprising 50% on haemodialysis (HD), 12% on continuous ambulatory peritoneal dialysis (CAPD) and 38% with functioning transplants. the prevalence rate for dialysis was 68 per million population (p.m.p.) and that of transplant 42 p.m.p. the new dialysis acceptance rate was 15 p.m.p. and transplant 5 p.m.p. Forty-seven per cent of new patients had unknown primary renal disease and 30% was due to non-insulin dependent diabetes mellitus. Mean age of prevalent HD patients was 42 years, CAPD 46 years and 34 years for transplant. Patient survival on CAPD was 85% at 1 year and for HD was 88%. One year transplant patient survival was 94% and graft survival 91%.     

Malaysian Dialysis and Transplant Registry Report

This report summarizes data for dialysis and transplant patients up to the end of 1995. We estimate coverage to be about 30% of dialysis patients and near complete ascertainment of transplant patients. On the 31 December 1995, there were 2224 patients on renal replacement therapy (RRT), comprising 50% on haemodialysis (HD), 12% on continuous ambulatory peritoneal dialysis (CAPD) and 38% with functioning transplants. The prevalence rate for dialysis was 68 per million population (p.m.p.) and that of transplant 42 p.m.p. The new dialysis acceptance rate was 15 p.m.p. and transplant 5 p.m.p. Forty-seven per cent of new patients had unknown primary renal disease and 30% was due to non-insulin dependent diabetes mellitus. Mean age of prevalent HD patients was 42 years, CAPD 46 years and 34 years for transplant. Patient survival on CAPD was 85% at 1 year and for HD was 88%. One year transplant patient survival was 94% and graft survival 91%.     

Chronic kidney disease in Costa Rica

Costa Rica is one of the Central American countries, located between Nicaragua to the north and Panama to the south. Like other Latin American countries, Costa Rica deals with social and economic problems associated with poverty, except for one significant difference-Costa Rica has not had an army since 1948, and so the people and government can spend more money on education and health. For this reason, Costa Rica is very different from other Latin American countries. We do not need weapons, and we have had a democratic tradition for 100 years. Despite our economic and social limitations, Costa Ricans have universal access to a health system that covers 98% of the inhabitants. Renal replacement therapy (RRT) is accessible to all who need it. In the last 5 years, Costa Rica has doubled the number of patients on hemodialysis, and has the highest number of kidney transplants per million population (pmp) in Latin America, with 20.63 transplants pmp in 2000, 27.25 transplants pmp in 2001, and 24.81 transplants pmp in 2002. However, the prevalence of all forms of RRT in Costa Rica is currently 193 pmp. This suggests that end-stage renal disease is underdiagnosed in Costa Rica as it is in many other Latin American countries. Greater research efforts are needed to determine the true extent of renal disease in Costa Rica and to optimize the use of health-sector resources to provide a better and more robust program of RRT for patients with end-stage renal disease.     

La néphrologie en Tunisie : d’hier à aujourd’hui

Professor Hassouna Ben Ayed is the founder of Tunisian nephrology. He introduced in 1962 the first artificial kidney for the treatment of acute renal failure. In 1963, the first acute peritoneal dialysis was done. Renal biopsy started in 1967 with general pathologists. A special laboratory of renal pathology was set up in 1975 with Pr H. Ben Maïz. Epidemiology of glomerular diseases, when histologically proven, was published [8]. A comprehensive program of chronic hemodialysis was started in 1968 and was developed markedly since 1975 with Pr A. El Matri. An intermittent peritoneal dialysis programme was started in 1982 and CAPD in 1983 by Pr T. Ben Abdallah. The Tunisian renal failure patient association was created in 1982 and the Tunisian society of nephrology in November 1983. A national registry for ESRD treatment is available since 1986. Since this time, the number of patients initiating renal replacement therapy (RRT) for ESRD has increased dramatically due to the extension of acceptance criteria for RRT and the increase of the elderly population. The incidence was 13 pmp in 1986 and 133 pmp in 2008. The prevalence was 48.5 pmp in 1986 and 734 pmp in 2008. From 1971 up to 1986, locally dialysed patients have been transplanted abroad, especially in France. On 4 June 1986, the local transplantation program was started at Charles Nicolle Hospital in Tunis. A national center of organ transplantation was created on 12 June 1995. At the end of 2008, there were106 nephrologists, 26 residents in nephrology and 253 doctors with a training in hemodialysis during 1 year. In university hospitals, the number of nephrology departments is five, with one unit in an army hospital and two units for pediatric nephrology. Five hospitals perform renal transplantation (Tunis: 2 – Sfax: 1 – Sousse: 1 – Monastir: 1). There are 138 centers of hemodialysis: 39 public, 99 private. Seven thousand and eighty patients were treated by HD, 127 patients underwent renal transplantation. The vast majority of these transplants have been performed using living related donors (103/127). The cost of renal replacement therapy (RRT) is taken in charge by the Ministry of Health and the national security boards. Legislation on HD was promulgated by the Tunisian government, setting rigorous and detailed rules for the implementation of new dialysis centers, as well as for the functioning of already active units (4 August 1986 – 4 April 1998). For transplantation, legislation was promulgated on 25 March 1991.     

2017 Annual Report Digest of the Renal Epidemiology Information Network (REIN) registry

The French Renal Epidemiology and Information Network (REIN) registry started in 2002 with the goal to provide a tool to evaluate renal replacement therapy (RRT) practices and outcomes, to provide data for research and to support public health decisions related to end‐stage renal disease ESRD. This summary presents the incidence and prevalence of RRT including kidney transplantation and wait‐listing activity in 2017, and patients’ survival and trends over 5 years. In 2017, 11 543 patients started RRT for ESRD, that is, incidence of 172 pmp. Between 2012 and 2017, the incidence of RRT increased by 1% per year [CI 95% (0.0; +2.0)]. On 31 December 2017, 87 275 patients were receiving RRT, that is, prevalence of 1294 pmp, 55% on dialysis, 45% with a functioning transplant. In 2017, 3782 kidney transplantations have been performed including 16% from a living donor, 13% being retransplantations and 15% pre‐emptive transplantations. The median time on the waiting list was 19.7 months when only taking into account active waiting periods on the list. In 2017, 5280 new patients were registered on the renal transplant waiting list (i.e. 78.7 pmp). The number of patients considered as ‘inactive’ represented 45% of the patients on the list.     

The 2008 ERA-EDTA Registry Annual Report-a précis

Background. This study provides a summary of the 2008 ERA-EDTA Registry Report (this report is available at www.era-edta-reg.org).Methods. The data on renal replacement therapy (RRT) were available from 55 national and regional registries in 30 countries in Europe and bordering the Mediterranean Sea. Datasets with individual patient data were received from 36 registries, whereas 19 registries contributed data in aggregated form. We presented incidence and prevalence of RRT, and transplant rates. Survival analysis was solely based on individual patient records.Results. In 2008, the overall incidence rate of RRT for end-stage renal disease (ESRD) among all registries reporting to the ERA-EDTA Registry was 122 per million population (pmp), and the prevalence was 644?pmp. Incidence rates varied from 264?pmp in Turkey to 15?pmp in Ukraine. The mean age of patients starting RRT in 2008 ranged from 69?years in Dutch-speaking Belgium to 44?years in Ukraine. The highest prevalence of RRT for ESRD was reported by Portugal (1408?pmp) and the lowest by Ukraine (89?pmp). The prevalence of haemodialysis on 31 December 2008 ranged from 66?pmp (Ukraine) to 875?pmp (Portugal) and the prevalence of peritoneal dialysis from 8?pmp (Montenegro) to 115?pmp (Denmark). In Norway, 70% of the patients on RRT on 31 December 2008 were living with a functioning graft (572?pmp). In 2008, the number of transplants performed pmp was highest in Spain (Catalonia) (64?pmp), whereas the highest transplant rates with living-donor kidneys were reported from the Netherlands (25?pmp) and Norway (21?pmp). In the cohort 1999-2003, the unadjusted 1-, 2- and 5-year survival of patients on RRT was 80.8% (95% CI: 80.6-81.0), 69.1% (95% CI: 68.9-69.3) and 46.1% (95% CI: 45.9-46.3), respectively.     

Comparing mortality of elderly patients on hemodialysis versus peritoneal dialysis: a propensity score approach

The objective of this study was to evaluate differences in mortality over the first year of renal replacement therapy (RRT) between elderly patients starting treatment on hemodialysis (HD) versus peritoneal dialysis (PD). For the period of 1991 to mid-1996, this study defined an inception cohort of all patients aged >65 yr with new-onset chronic RRT who were New Jersey Medicare and/or Medicaid beneficiaries in the year before RRT and who had been diagnosed with renal disease more than 1 yr before RRT. Propensity scores were calculated for first treatment assignment from a large number of baseline covariates. Mortality was then compared among patients initially assigned to HD versus PD using multivariate 90-d interval Cox models controlled for propensity scores and center stratification. Peritoneal dialysis starters had a 16% higher rate of death during the first 90 d of RRT compared with HD patients (hazard ratio [HR], 1.16; 95% confidence interval [CI], 0.96 to 1.42)]. Mortality did not differ between day 91 and 180 (HR, 1.03; 95% CI, 0.71 to 1.51). Thereafter, PD starters again died at a higher rate (HR, 1.45; 95% CI, 1.07 to 1.98). These findings were more pronounced among patients with diabetes. Sensitivity analyses using more stringent criteria to ensure that first treatment choice reflected long-term treatment choice confirmed the presence of an association between PD and mortality. In conclusion, compared with HD, peritoneal dialysis appears to be associated with higher mortality among older patients, particularly among those with diabetes, even after controlling for a large number of risk factors for mortality, propensity scores to control for nonrandom treatment assignment, and center stratification.     

Late referral and modality choice in end-stage renal disease

BACKGROUND: We sought to determine whether late versus early referral to a nephrologist in patients with chronic kidney disease influences the initial choice of hemodialysis (HD) versus peritoneal dialysis (PD) or the likelihood of switching treatment modalities in the first six months of therapy. METHODS: Using New Jersey Medicare/Medicaid claims, all patients who started RRT between January 1991 and June 1996 and were diagnosed with renal disease more than one year prior to RRT were identified. In the resulting cohort of 3014 patients, 35% had their first nephrologist consultation < or =90 days prior to initiation of dialysis. RESULTS: After controlling for demographic characteristics, socioeconomic status and underlying renal disease, age, black race [Odds ratio (OR) = 0.56], race other than black or white (OR = 0.56), and socioeconomic status (OR = 0.68) influenced the choice of initial treatment modality, but timing of the referral did not. However, patients starting on PD who were referred late were 50% more likely to switch to HD than were patients who saw a nephrologist earlier [Hazard's ratio (HR) = 1.47]. In patients originally on HD, diabetic nephropathy (HR = 1.49) and black race (HR = 0.69) influenced the likelihood of switching to PD, but the timing of referral did not. CONCLUSIONS: These results refute earlier findings that late referral may limit access to PD. We found that modality choice depends on factors such as age, race, or socioeconomic status, rather than on than timing of nephrologist referral. Late referral does not influence the likelihood to switch modality in patients starting on HD, but does so in patients starting on PD.     

Renal replacement therapy options from an Indian perspective: dialysis versus transplantation

In developing countries such as India, the management of end-stage renal disease (ESRD) is largely guided by economic considerations. In the absence of health insurance plans, fewer than 10% of all patients receive renal replacement therapy (RRT). Hemodialysis (HD) is mainly a short-term measure to support ESRD patients prior to transplant. Infections are common in dialysis patients. The majority of patients starting HD die or are forced to abandon treatment because of cost constraints within the first 3 months. The cost of peritoneal dialysis (PD) is two times higher than that of HD, fewer than 2% of patients are started on PD. Among the three RRT options available, renal transplant is the preferred mode, as it is most cost-effective and provides a better quality of life. But due to financial constraints and nonavailability of organs, only about 5% of ESRD patients undergo transplant surgery. Though the removal of organs from brain-dead patients has been legalized, the concept of donation of organs from deceased donors has not received adequate social sanction. Only 2% of all transplants are performed from deceased donors. Due to limited access to RRT, the ideal approach should be to reduce the incidence of ESRD and attempt preventive measures. Preemptive transplant, reducing the duration of dialysis prior to transplant, use of immunosuppression for only up to 1 year, and availability of more deceased donor organs may be helpful to make RRT options within the reach of the common man.     

Current structure and organization for renal patient assistance in Italy

Background. Given the public health challenge and burden ofchronic kidney disease, the Italian Society of Nephrology (SIN)has compiled a national census of Renal Units (RU) existingin the twenty Italian regions related to the year 2004. Methods. An on-line questionnaire including 158 items exploredstructural and human resources, organization aspects, activitiesand epidemiological data in SIN, 2004. Results. The census identified 363 public RU, 303 satelliteDialysis Centres (DC) and 295 private DC totalling 961 DC [16.4per million population (pmp)]. The inpatient renal beds were2742 (47 pmp). Renal and dialysis activity was performed by3728 physicians (64 pmp), of whom 2964 (80%) were nephrologists.There was no permanent medical assistance in 41% of satelliteDC. There were 1802 renal admissions pmp and 99 renal biopsiespmp. The management of acute renal failure (13 456 cases;230 pmp) represented a relevant proportion of the activitiesconducted in public RU. In 2004 there were 9858 new cases ofend-stage kidney disease requiring renal replacement therapy(RRT) (169 pmp). On 31 December 2004, 60 058 patients wereon RRT (1027 pmp), 43 293 of which (740 pmp) were on dialysisand 16 765 (287 pmp) with renal graft. Conclusions. This census of the Italian RU and DC in 2004 providesdecision makers and healthcare stakeholders with detailed datafor benchmarking and has financial implications for the publichealth system. Similar analyses may be conducted in other countriespermitting standardization of medical and cost-related aspectsof renal care.     

The cost-effectiveness of increasing kidney transplantation and home-based dialysis

Background:   Renal replacement therapy (RRT) consumes sizable proportions of health budgets internationally, but there is considerable variability in choice of RRT modality among and within countries with major implications for health outcomes and costs. We aimed to quantify these implications for increasing kidney transplantation and improving the rate of home-based dialysis.
Methods:   A multiple cohort Markov model was used to assess costs and health outcomes of RRT for new end-stage kidney disease (ESKD) patients in Australia for 2005–2010, using a health-care funder perspective. Patient characteristics and current practice patterns were based on the ANZDATA Registry. Two proposed changes were modelled: (i) increasing kidney transplants by between 10% and 50% by 2010; and (ii) increasing home haemodialysis (HD) and peritoneal dialysis (PD) to the highest rates observed among Australian centres. We assessed costs (Australian dollars), survival and quality-adjusted survival, and cost-effectiveness.
Results:   The number of new ESKD patients in 2010 was estimated to be 2700, with annual RRT costs of about $A700 million; cumulative costs (2005–2010) were $A5 billion. Increasing transplants by 10–50% saves between $A5.8 and $A26.2 million, and increases quality-adjusted life years (QALYs) by 130–658 QALYs. Switching new patients from hospital HD to (i) home HD saves $A46.6 million by 2010; or (ii) PD saves $A122.1 million.
Conclusions:   These clinical practice changes reduce costs, improve patient quality of life and, in the case of transplantation, increase survival. Planning for RRT services should incorporate efforts to maximize rates of transplantation and to encourage home-based over hospital-based dialysis to optimize cost-effectiveness in RRT service delivery.     

Burden of disease - prevalence and incidence of ESRD in selected European regions and populations

Rates of renal replacement therapy (RRT) vary markedly between Eastern and Western European countries. This review aims to establish the characteristics of healthcare systems and renal services that are independently associated with rates of initiation of RRT in these countries. The incidence of RRT varied from 12 to 455 per million populations (pmp); the only general population indicator independently associated with RRT incidence was aged 65+. Economic and financial conditions could also play an important role. Gross Domestic Product (GDP) per capita and the proportion of GDP spent on healthcare independently predicted RRT incidence. Each increase in hemodialysis (HD) facilities and competition between providers is associated with higher RRT incidence. In this context, macroeconomic and potentially modifiable renal service organizational factors appear more important determinants of provision of RRT than measurable medical factors. The economic, financial or medical conditions could also play an important role in treatment strategy. The proportion of patients receiving HD, peritoneal dialysis (PD) or transplantation shows marked variation in Europe. The East Europeans use more HD and less RTx as compared to West Europeans; the use of PD is similar. Treatment of anemia and mineral metabolism disorders also varies from one region to another. The mean baseline hemoglobin level and the prevalence of patients reaching this value are higher in West Europeans. Regarding mineral metabolism, the percent of patients achieving all four parameters (Ca, P, CaxP and PTH) was also higher in Western Europe. The adherence to EBPG (European Best Practice Guidelines) was also higher in these countries.     

Cost of renal replacement therapy in Turkey

BACKGROUND AND RESULTS: By the end 2000, 22224 patients were on renal replacement therapy (RRT) in Turkey. We investigated the cost of RRT in three medical faculties and one private dialysis centre. Yearly expenses were US dollars 22759 for haemodialysis (HD), US dollars 22350 for continuous ambulatory peritoneal dialysis (CAPD), and US dollars 23393 and US dollars 10028, respectively, for the first and second years of transplantation (Tx). In the first year, renal Tx was significantly more expensive than CAPD. However, after the first year of renal transplantation, Tx became significantly more economical than both CAPD and HD. The sum of all yearly RRT expenses for the country was US dollars 488958709, which corresponds to nearly 5.5% of Turkey's total health expenditure. CONCLUSION: Measures such as early construction of vascular access, promoting home dialysis and the reuse of the dialysers, strict control of the use of some expensive drugs like erythropoietin and active vitamin D, and also increasing the number of transplantations, especially if pre-emptive transplantation is possible, should be taken into account in order to reduce these expenses.     

Nephrology, dialysis and transplantation in Turkey.

The establishment of the Turkish Society of Nephrology (TSN) in 1970 coincided with that of many western European nephrology societies. The TSN organized the 15th ERA-EDTA Congress in Istanbul in 1978, earlier than many European Countries, and currently has 286 active members. At present, Turkey has 161 nephrologists, which equals 2.5 nephrologists per million population (p.m.p.). The number of original articles submitted by Turkish authors to the journal Nephrology Dialysis Transplantation ranks 7th-8th amongst total submissions to the journal. Turkey also ranks 2nd-4th in the number of abstracts submitted to recent ERA-EDTA Congresses. With 18 063 patients undergoing intermittent haemodialysis treatment in 348 dialysis centres, Turkey has the 5th largest chronic haemodialysis patient population among European countries. In addition, 1903 patients are currently undergoing continuous ambulatory peritoneal dialysis. However, with a total of 4693 renal transplants since 1975, of which only 21.3% were of cadaveric origin, Turkey lags considerably behind other European countries in renal transplantation. In Turkey, the prevalence and incidence of renal replacement therapy (RRT) are at present 358 and 52 p.m.p. respectively, and the expansion rate of the RRT stock is 17% (HD 18.5%, CAPD 6%, and transplantation 1.7%). The yearly gross mortality rate of the total RRT population is 9.4%. The present priorities of the Turkish nephrological community include high-standard research activity and long-term, prospective clinical and epidemiological studies, an increase in the total number and percentage of cadaveric transplants, further improvement of the quality and cost-effectiveness of RRT, and finally the further development of scientific and educational collaboration with the world nephrological community.     

Should CAPD be the first choice for dialysis in Romania? Audit of the Iasi 'C. I. Parhon' Dialysis Center: 1995-2000.

Peritoneal dialysis was first introduced in Romania in 1995.We are reporting data on patient and technique outcomes, basedon the 5-year experience of one of the first two Romanian continuousambulatory peritoneal dialysis (CAPD) centres. During this period,Romania had the highest rate of increase in renal replacementtherapy (RRT) and CAPD (28 times over baseline) in Europe: CAPDincrease in Romania vs Eastern Europe was 6.7 compared to asimilarly defined ratio of 5.6 for haemodialysis (HD). Between 1995 and 2000, at the ‘C. I. Parhon’ Hospitalin Iasi, 259 patients were started on HD and 102 on CAPD. The90 CAPD patients we followed were treated for a total of 1896months. 86.7% of the patients were alive on 31 July 2000—67.8%continuing on CAPD, 15.6% on HD and 3.3% transplanted. The 61patients still on PD on that date, represented 11.1% of theactual Romanian CAPD population and 31% of our RRT population(compared to 13.7% nationwide). The gross mortality rate was comparable to the mean calculatedfor the HD population nationwide. Mean survival of the CAPDpatients was 45.4±2.6 months (95% CI=40.4–50.4months). One-year and 5-year patient survival rates were 97.5%and 52.7% respectively, superior and similar to mean figuresnationwide. Mean technique survival was 36.6±0.6 months(95% CI=31.5–41.6 months). One- and 5-year technique survivalrates were 83.1% and 34.3% respectively. Technique failure wasmainly due to dialysis inefficiency: 50% of cases. Mean weeklyKt/V for the 5-year period was 1.92±0.21 while mean weeklycreatinine clearance was 61.2±12.4 ml/1.73 m²/week. Eighty-four episodes of peritonitis were recorded in 46 patients(0.25 episodes/patient/year); mean duration to peritonitis was23 months (95% CI=18.2–27.5). Malnutrition was noted (SGAscore) in 25.5% of the cases. Blood pressure (assessed by 24-hABPM) was adequately controlled in 83.3% of the patients. Leftventricular hypertrophy was ubiquitous (77.7%), but left ventriculardilatation and systolic dysfunction (fractioning shorteningindex <25%) were rare—4.4% and 3.3% respectively (similarin prevalence to the Iasi HD population). No statistically significantchanges in echocardiographic parameters were recorded betweenthe first and subsequent years on CAPD treatment. Peritoneal dialysis had a rapid increase in the last 5 yearsin Romania and particularly in the region of Moldova. Outcomesand complication rates are equal or superior to nationwide HDdata and comparable to distinguished centres of CAPD in economicallydeveloped countries. We conclude that, provided that optimalmedical practice is available, CAPD should be the RRT of choicein Romania, and that it represents the only solution to thecountry's limited dialysis resources.     

CAPD and renal transplantation

Continuous ambulatory peritoneal dialysis (CAPD) is believed to improve the immune competence of end-stage renal failure patients and to increase the risk of graft rejection following subsequent renal transplantation. At this centre, 220 consecutive renal transplants have been studied in patients treated by either CAPD or haemodialysis (HD). Patient and graft survival was not significantly different for the two treatment groups over a five year follow-up. When only first cadaver recipients were considered (152 grafts) one-year graft survival (non-immunological failures excluded) was 77 per cent for CAPD and 79 per cent for HD patients (P greater than 0.05). Time on dialysis and number of pre-operative transfusions were significantly greater for the HD patients (P less than 0.05). A group of HD and CAPD patients were identified as being matched for age, sex, HLA, A, B, DR antigen matches, pre-operative transfusions and time-on dialysis. One-year graft survival of the CAPD patients was 82 per cent and for the HD patients 61 per cent. Studies of patient lymphocyte function and plasma suppressive activity in vitro revealed no differences between CAPD and HD treated patients. CAPD is not an immunological risk factor in renal transplantation and its continued use in the preparation of patients for transplantation is recommended.