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Keywords:

  • End-stage renal disease;
  • Epidemiology;
  • Hemodialysis;
  • Kidney transplantation;
  • Peritoneal dialysis

Abstract

  1. Top of page
  2. Abstract
  3. Renal Centers
  4. Incident Patients
  5. Prevalent Patients
  6. Mortality in RRT Patients
  7. Hemodialysis Prescription in Prevalent Patients
  8. Vascular Access in Prevalent and Incident Patients
  9. Kidney Transplantation
  10. Conclusions
  11. Acknowledgments
  12. References

This report provides a summary of the 2011 Slovenian renal replacement therapy (RRT) data. Data were obtained from 24 renal centers: 23 dialysis and one transplant center, referred as of 31 December 2011, with 100% response rate to individual patient questionnaires. Slovenia has a population of approximately 2 million (2 052 496 in 2011). The total number of patients treated by RRT was 2011,that is, 980 per million of population (pmp); 0.4% decrease compared to 2010. 1347 (67.0%) were treated by hemodialysis, 60 (3.0%) by peritoneal dialysis, and 604 (30.0%) had a functioning kidney graft. A total of 236 incident patients, 115 pmp (at day one), started RRT, their median age was 68 years, 64.8% were men, 36.4% were diabetics. Regarding hemodialysis patients, 59.3% were treated with on-line hemodiafiltration, 86% with ultrapure dialysis fluid. Median weekly duration of hemodialysis was 12.5 h, median dry body weight 70 kg, mean blood flow 275 ± 46 mL/min, 7.1% were dialyzed in a single-needle mode. Vascular accesses were native arteriovenous fistula in 79%, polytetrafluoroethylene graft in 6%, and catheter in 15%. The crude death rate was 15.9% in dialysis patients, 1.9% in transplant recipients, and 12.0% in all RRT patients (both dialysis and transplant, incident patients at day 1 included). Slovenia has been a member of Eurotransplant since 2000. Forty-six kidney transplantations were performed in 2011, all from deceased donors. A slight decrease in prevalent number of RRT patients was observed in 2011, for the first time in 40 years. The number and proportion of patients with functioning kidney grafts is increasing, reaching 30% in 2011.

The present report provides a summary on epidemiology and treatment practices in ESRD patients treated with renal replacement therapy (RRT) in Slovenia in 2011. The report is based on individual and center questionnaires prepared by the Slovenian Renal Replacement Therapy Registry Group. The response rate to the questionnaires was 100%. Pediatric data has also been included.

The chronic HD program started in Slovenia in 1970 – the same year the first kidney transplantation from living related donor was performed. Annual reports on RRT epidemiology were initiated in 1999 and were prepared by the expert group for dialysis. These reports were initially based on data from renal center questionnaires [1, 2]. In 2002, we began collecting individual patient data as well, and by 2004, a response rate of 100% was achieved for individual patients. With these data, the Slovenian RRT registry joined the ERA/EDTA (European Renal Association-European Dialysis and Transplant Association) registry (Section B, aggregated data) [3], and the Slovenian RRT Registry Group was founded, sponsored by the Slovenian Society of Nephrology, with reports published in international journals [4, 5]. The registry is voluntary. In 2007, we added our individual patient data to the ESPN (European Society for Pediatric Nephrology) Registry [6]. Slovenian RRT Registry has been a partner in the NephroQUEST study [7] and the EVEREST study [8]. The general population of Slovenia is about 2 million (in 2011: 2 052 496; 1 037 066 women and 1 015 430 men).

The aims of the registry, which collects data on individual RRT patients as well as data on renal center characteristics, are: (i) to be informed on the number of patients and their characteristics, (ii) to monitor and improve the quality of RRT care, (iii) to compare Slovenian RRT care with that of other countries, (iv) to use registry data for the planning of health care facilities and personnel, and (v) to use registry data for the research.

Renal Centers

  1. Top of page
  2. Abstract
  3. Renal Centers
  4. Incident Patients
  5. Prevalent Patients
  6. Mortality in RRT Patients
  7. Hemodialysis Prescription in Prevalent Patients
  8. Vascular Access in Prevalent and Incident Patients
  9. Kidney Transplantation
  10. Conclusions
  11. Acknowledgments
  12. References

On 31 December 2011, there were 24 renal centers in Slovenia: 16 in-hospital dialysis centers, seven private, out-patient HD centers (five of them owned by Fresenius Medical Care), and one transplant center. One of the 16 in-hospital centers is the Center for Pediatric Dialysis and Transplantation, and another is the Center for Peritoneal Dialysis at the University Medical Center Ljubljana, but peritoneal dialysis is also performed at eight in-hospital dialysis centers in Slovenia.

Incident Patients

  1. Top of page
  2. Abstract
  3. Renal Centers
  4. Incident Patients
  5. Prevalent Patients
  6. Mortality in RRT Patients
  7. Hemodialysis Prescription in Prevalent Patients
  8. Vascular Access in Prevalent and Incident Patients
  9. Kidney Transplantation
  10. Conclusions
  11. Acknowledgments
  12. References

Incident patients at day 1

There were 236 incident patients (incident rate 115.0 per million of population [pmp]), of these 153 were men (64.8%, incident rate 150.7 pmp) and 83 were women (35.2%, incidence rate 80.0 pmp). The (age and gender) adjusted incidence rate pmp (with a general population of EU27 of year 2005 used for the adjustment calculation) was 107.4 pmp, men 142.9 pmp and women 73.6 pmp. The mean age was 66.5 ± 14.2 years (median 68 years), the mean age of men was 63.8 ± 14.3 years (median 64.0 years) and the mean age of women was 71.3 ± 12.8 years (median 74.0 years). Three patients starting RRT were <20 years old. The number and median age of incident patients over the past years is shown in Figure 1; the number of new patients starting renal replacement therapy is relatively stable, while the median age has increased a trend, which is also observed in other registries.

figure

Figure 1. The number and median age of incident (day 1) renal replacement therapy patients by calendar year.

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The primary renal diseases in incident patients at day 1 in 2011 were: diabetic nephropathy: type 1: 0.4%, type 2: 26.7%, both 27.1%; hypertension 14.4%; renovascular disease 3.8%; glomerulonephritis 13.6%; polycystic kidney disease 6.8%; pyelonephritis 6.4%; miscellaneous (other) 10.6%; unknown: 17.4%. Diabetes, recorded as a comorbidity, was present in 86/236 (36.4%) of incident patients.

Incident patients at day 91

There were 216 incident patients alive and on RRT at day 91, (incident rate 105.3 pmp), of these 139 were men (64.4%, incidence rate 136.9 pmp) and 77 were women (35.6%, incidence rate 74.3 pmp). The adjusted incidence rate pmp (with a general population of EU27 of year 2005 used for the adjustment calculation) was 99.3 pmp, for men 130.5 pmp and women 69.2 pmp. The mean age was 65.9 ± 14.3 years (median 68.0 years), the mean age of men was 63.5 ± 13.7 years (median 63.0 years) and the mean age of women was 70.2 ± 14.5 years (median 73.0 years). Three patients were <20 years old. The primary renal diseases in incident patients at day 91 were almost the same as in incident patients at day 1.

Prevalent Patients

  1. Top of page
  2. Abstract
  3. Renal Centers
  4. Incident Patients
  5. Prevalent Patients
  6. Mortality in RRT Patients
  7. Hemodialysis Prescription in Prevalent Patients
  8. Vascular Access in Prevalent and Incident Patients
  9. Kidney Transplantation
  10. Conclusions
  11. Acknowledgments
  12. References

On 31 December 2011, there were 2011 prevalent RRT patients in Slovenia with a prevalence rate of 980.0 pmp, 1194 men (1176.4 pmp) and 817 women (787.8 pmp). Men represented 59.4% of the prevalent RRT patients. The mean age of prevalent patients was 59.4 ± 15.6 years (median 60 years). The mean age of prevalent men was 59.0 ± 14.9 years (median age 59 years) and of women 60.1 ± 16.4 years (median 60 years). Sixteen patients were <20 years of age.

The primary renal diseases in prevalent RRT patients in 2011 were: diabetic nephropathy type 1 4.2%, type 2 10.2%, both 14.4%; hypertension 8.9%, renovascular disease 1.1%; glomerulonephritis 22.3%; polycystic kidney disease 9.1%; pyelonephritis 10.3%; miscellaneous (other) 20.2%; unknown 13.6%. Diabetes, recorded as a comorbidity, was present in 474/2011 (23.6%) of prevalent patients.

The number of prevalent ESRD patients on different forms of renal replacement therapy are presented in Table 1 and Figure 2. The unadjusted, per million of the population, prevalent and incident (day 1) number of patients are shown in Table 2. In 2011, for the first time since the start of the Registry in 2004, there was a small decrease of 0.4% in the number of prevalent patients. Among all the prevalent patients, 1347 (67.0%) were treated by HD (a 2.2% decline as compared to 2010), 60 (3.0%) by peritoneal dialysis (a 6.3% decrease), and 604 (30.0%) had a functioning kidney graft (a 4.3% increase). Over the past years, there has been a slow decrease of peritoneal dialysis patients, and a steady increase in transplanted patients, while the number of HD patients has started to decrease for the first time in 2010 and continued in 2011 (see Table 1 and Fig. 2).

figure

Figure 2. The number of prevalent patients on different forms of renal replacement therapy from 2000–2011 (HD, hemodialysis; PD, peritoneal dialysis; TX, kidney transplantation).

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Table 1. Prevalence of end-stage renal disease patients on different forms of renal replacement therapy on 31 December in the period from 2000–2011 (residents only)
31 DecemberHemodialysisPeritoneal dialysisFunctioning graftAll
  1. a

    Based on individual patient data.

2000 (N)10511172671435
2001 (N)11251133041542
2002 (N)11311103431584
2003 (N)11711163741661
2004a (N)12021194151736
2005a (N)12601154271802
2006a (N)12711034611835
2007a (N)1318974821897
2008a (N)13431055191967
2009a (N)1400775372014
2010a (N)1377645792020
2011a (N)1347606042011
Increase 2001 (N/%)74/7.0%−4/−3.4%37/13.9%107/7.5%
Increase 2002 (N/%)6/0.5%−3/−2.7%39/12.8%42/2.7%
Increase 2003 (N/%)40/3.5%6/5.5%31/9.0%77/4.9%
Increase 2004a (N/%)31/2.6%3/2.6%41/11.0%75/4.9%
Increase 2005a (N/%)58/4.8%−4/−3.4%12/2.9%66/3.8%
Increase 2006a (N/%)11/0.9%−12/−10.5%34/8.0%33/1.8%
Increase 2007a (N/%)47/3.7%−6/−5.8%21/4.6%62/3.4%
Increase 2008a (N/%)25/1.9%8/8.2%37/7.7%70/3.7%
Increase 2009a (N/%)57/4.2%−28/−27%18/3.5%47/2.4%
Increase 2010a (N/%)−23/−1.6%−13/−17%42/7.2%6/0.3%
Increase 2011a (N/%)−30/−2.2%−4/−6.3%25/4.3%−9/−0.46%
Table 2. Number of unadjusted prevalent and incident (day 1) patients per million of the population (pmp) from 2000–2011
31 DecemberPrevalence pmpIncidence pmp
  1. a

    Based on individual patient data.

2000723109
2001771144
2002807115
2003846131
2004a869125
2005a901125
2006a913124
2007a936118
2008a968116
2009a986121
2010a994119
2011a980115

Mortality in RRT Patients

  1. Top of page
  2. Abstract
  3. Renal Centers
  4. Incident Patients
  5. Prevalent Patients
  6. Mortality in RRT Patients
  7. Hemodialysis Prescription in Prevalent Patients
  8. Vascular Access in Prevalent and Incident Patients
  9. Kidney Transplantation
  10. Conclusions
  11. Acknowledgments
  12. References

A total of 241 patients on RRT died in 2011 (incident [day 1] patients were included), of these 141 were men (58.5%) and 100 were women. Their mean age was 71.1 ± 12.2 years (median 73) and their mean RRT vintage was 6.3 ± 6.8 years (median 4.1). Of these, 230 were dialysis patients (223 HD and seven peritoneal dialysis) and 11 were kidney graft recipients. The crude death rate for dialysis patients in 2011 was 15.9% (16.1% for HD patients and 11.3% for PD patients), 1.9% for transplanted patients, and 12.0% for all RRT patients. Crude death rate of RRT patients from years 2000 to 2011, with incident patients at day one included is presented in Table 3. The most common causes of death in all renal replacement therapy patients are shown in Figure 3. The longest RRT survivor in Slovenia is a 70-year old woman, treated by chronic HD for 40 years and 3 months.

figure

Figure 3. Causes of death in all deceased renal replacement therapy patients in year 2011 (N = 241).

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Table 3. Crude death rate of renal replacement therapy (RRT) patients in the period from 2000–2011 (incident patients at day 1 included)
YearAll RRTAll dialysis (HD+PD)HDPDTX
  1. HD, hemodialysis; PD, peritoneal dialysis; TX, transplanted patients.

2000 10.4%10.8%7.3% 
2001 10.4%10.5%9.6% 
2002 12.9%13.2%9.8% 
2003 11.8%12.0%9.8% 
2004 12.6%13.1%8.3% 
200510.0%12.8%13.4%6.8%0.9%
200611.4%14.7%15.6%4.6%1.4%
20079.0%11.6%12.3%2.0%1.5%
20089.4%12.4%12.5%9.1%1.6%
200910.6%13.3%13.9%5.5%2.8%
201011.4%15.0%15.6%4.3%1.8%
201112.0%15.9%16.1%11.3%1.9%

Hemodialysis Prescription in Prevalent Patients

  1. Top of page
  2. Abstract
  3. Renal Centers
  4. Incident Patients
  5. Prevalent Patients
  6. Mortality in RRT Patients
  7. Hemodialysis Prescription in Prevalent Patients
  8. Vascular Access in Prevalent and Incident Patients
  9. Kidney Transplantation
  10. Conclusions
  11. Acknowledgments
  12. References

In 2011 67.0% (1347/2011) of prevalent RRT patients were treated with chronic HD, 61.2% were men, their mean age was 64.6 ± 14.2 years (median 67 years, range 11–94), 18.4% were classified as having diabetic nephropathy as the primary renal disease, and 29.2% were reported as having diabetes.

Regarding HD technique, the percentage of patients treated with convective techniques has increased in the past years, as shown in Figure 4, and the majority of patients (799, 59.3%) were treated with hemodiafiltration, 532 with bicarbonate HD and 16 patients with hemofitration. In the majority of HD patients (86.0%), ultrapure dialysis fluid was used (including patients treated with convective techniques).

figure

Figure 4. Prevalent hemodialysis patients by dialysis technique (HD, bicarbonate hemodialysis; HDF, online hemodiafiltration; HF, hemofiltration).

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A minority of patients was treated with twice-weekly dialysis (9.2%, N = 124) or once-weekly HD (0.5%, N = 7), 15 patients (1.1%) with 4-times-weekly HD, and the vast majority, 89.0% (1200/1347), were treated with 3-times-weekly HD. Ninety-six patients (7.1%) were dialyzed in the single-needle dialysis mode. The average weekly time on dialysis was 12.9 ± 2.5 h (3–24 h, including patients treated with once- or twice-weekly dialysis), the median weekly time on HD was 12.5 h. Regular night-shift in-hospital HD was offered at the Dialysis Center Zaloška to employed patients, students and pupils.

The mean dry body weight of HD patients was 71.5 ± 16.6 kg (median 70 kg). The mean blood flow was 275 ± 46 mL/min (range 110–450). Anticoagulation was performed using low molecular weight heparin in 17.8% of HD patients, while unfractioned heparin was used in the majority (79.3%) of HD patients.

Vascular Access in Prevalent and Incident Patients

  1. Top of page
  2. Abstract
  3. Renal Centers
  4. Incident Patients
  5. Prevalent Patients
  6. Mortality in RRT Patients
  7. Hemodialysis Prescription in Prevalent Patients
  8. Vascular Access in Prevalent and Incident Patients
  9. Kidney Transplantation
  10. Conclusions
  11. Acknowledgments
  12. References

The vascular accesses in 1347 prevalent chronic HD patients on 31 December 2011, were: native arteriovenous fistula (AVF) in 79% (N = 1066), PTFE (polytetrafluoroethylene) graft in 6% (N = 80), and catheter in 15% (N = 201). Hemodialysis catheters (N = 201) were: temporary (noncuffed) in 90.5% and permanent silastic in 9.5% (N = 19) of patients; precurved jugular in 83%, subclavian in 14%, and femoral in 3% of patients; single-lumen in 78% and double-lumen in 22% of patients. Vascular accesses in prevalent dialysis patients from 2005 to 2011 are presented in Figure 5. The otherwise high prevalence of AVF shows a negative trend in the past years in spite of good results with the placement of AVF in elderly patients [9]. One of the possible explanations is the increasing proportion of transplanted patients, with the “best” HD patients (usually with AVF) being transplanted.

figure

Figure 5. The type of vascular access in prevalent patients by calendar year (AVF, arterio-venous fistula).

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On 31 December 2011, there were 205 incident HD patients who were alive and on HD at day 91 (patients on PD are excluded), 65% were men, median age was 69.0 years (mean 66.8 ± 13.7, range 11–94 years), 38% were diabetic. The vascular accesses (on 31 December) were: native AVF in 52% (N = 107), PTFE graft in 3% (N = 6), and catheter in 45% (N = 92) of patients. The HD catheters were: temporary (non-cuffed) in all patients; precurved jugular in 83%, subclavian in 12% and femoral in 5% of patients; single-lumen in 84% and double-lumen in 16% of all cases.

Kidney Transplantation

  1. Top of page
  2. Abstract
  3. Renal Centers
  4. Incident Patients
  5. Prevalent Patients
  6. Mortality in RRT Patients
  7. Hemodialysis Prescription in Prevalent Patients
  8. Vascular Access in Prevalent and Incident Patients
  9. Kidney Transplantation
  10. Conclusions
  11. Acknowledgments
  12. References

There is one transplant center in Slovenia, located at the University Medical Center Ljubljana. Slovenia has been a member of Eurotransplant since 1 January 2000 [10]. In 2011, 46 kidney transplantations were performed (22.4 pmp), all from deceased donors. Eleven kidney graft recipients died in 2011 with a functioning kidney graft. The total number of patients (residents only) with a functioning kidney graft on 31 December 2011 was 604. Of these patients, 589 (97.5%) received grafts from deceased and 15 (2.5%) from living-related donors. The proportion of patients with functioning kidney graft (among all RRT patients) was 30% at the end of 2011. Graft and patient survival in Slovenia are superior to Eurotransplant average [10].

Conclusions

  1. Top of page
  2. Abstract
  3. Renal Centers
  4. Incident Patients
  5. Prevalent Patients
  6. Mortality in RRT Patients
  7. Hemodialysis Prescription in Prevalent Patients
  8. Vascular Access in Prevalent and Incident Patients
  9. Kidney Transplantation
  10. Conclusions
  11. Acknowledgments
  12. References

The incidence rate of end-stage renal disease patients requiring renal replacement therapy patients in Slovenia is stable or very slightly decreasing in the last years. After 40 years of increasing in prevalent number of renal replacement therapy patients, a slight decrease was observed in 2011, due to a decrease in the number of dialysis patients. The number and proportion of patients with functioning graft is steadily increasing. The majority of hemodialysis patients are treated in public, hospital units, with almost 60% treated by on-line hemodiafiltration. The mortality rate is increasing, for all renal replacement therapy patients. The longest renal replacement therapy survivor is a 70-year-old woman treated with chronic HD for 40 years and 3 months.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Renal Centers
  4. Incident Patients
  5. Prevalent Patients
  6. Mortality in RRT Patients
  7. Hemodialysis Prescription in Prevalent Patients
  8. Vascular Access in Prevalent and Incident Patients
  9. Kidney Transplantation
  10. Conclusions
  11. Acknowledgments
  12. References

This report was supported in part by Grant No. P3-0323-0312 of the Ministry of Education, Science and Technology of the Republic of Slovenia. We thank Cvetka Likar, renal nurse, for her dedicated work in collecting data. We also thank the nephrologists and nurses from all renal centers for their help in collecting the data.

Conflict of interest: None declared.

References

  1. Top of page
  2. Abstract
  3. Renal Centers
  4. Incident Patients
  5. Prevalent Patients
  6. Mortality in RRT Patients
  7. Hemodialysis Prescription in Prevalent Patients
  8. Vascular Access in Prevalent and Incident Patients
  9. Kidney Transplantation
  10. Conclusions
  11. Acknowledgments
  12. References