76
1 CKD and RENAL REPLACEMENT THERAPY IN ROMANIA 2013
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CKD and RENAL REPLACEMENT THERAPY IN ROMANIA2013
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THE ROMANIAN RENAL REGISTRYMinistry of Health“Dr Carol Davila” Clinical Nephrology HospitalCalea Griviţei nr 4, sector 1010731 BucharestRomaniaPhone: +40 21 3129226Fax: +40 21 3129226E-mail: [email protected] Website: under constructionPersonnel of the Romanian Renal RegistryProf Dr Gabriel MircescuDr Liliana GârneațăTechnicians: Eugen Podgoreanu, Viorica Ion, Daniela Isar
©Registrul Renal RomânReference suggestions: Annual Report of The Romanian Renal Registry 2012. Ministry of Health - Clinical Nephrology Hospital “Dr. Carol Davila” Bucharest, Romania, 2013
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Contents
List of fi gures ............................................................................................. 4
List of tables .............................................................................................. 8
List of appendices ...................................................................................... 9
Data source ............................................................................................. 12
Chronic kidney disease ........................................................................... 13
Data source ............................................................................................. 13
Defi niti ons ............................................................................................... 13
eGFR categories ....................................................................................... 13
Proteinuria categories ............................................................................. 14
Chronic kidney disease ............................................................................ 14
Strati fi cati on by risk ................................................................................. 15
Comorbiditi es in CKD ............................................................................... 16
Pati ents starti ng renal replacement therapy (incident pati ents) ............. 17
Pati ents under treatment (prevalent) ..................................................... 19
Dialysis pati ents ....................................................................................... 20
Hemodialysis pati ents ............................................................................. 23
Peritoneal dialysis pati ents ...................................................................... 24
Pati ents treated by other dialysis methods ............................................. 26
Transplant pati ents .................................................................................. 27
Territorial distributi on of the use of renal replacement therapy methods ... 29
The treatment for the replacement of renal functi ons in children ......... 32
Survival of the pati ents ............................................................................ 33
Standardized mortality rati o .................................................................... 33
Survival rates ........................................................................................... 35
Internati onal comparisons ...................................................................... 36
Incident pati ents...................................................................................... 36
Prevalent pati ents ................................................................................... 39
Replacement therapy method................................................................. 39
Survival of the renal replacement therapy pati ents ................................ 42
Dialysis service providers ........................................................................ 43
Organizati on and fi nancing ...................................................................... 46
Privati zati on and the public sector .......................................................... 46
The rati o between the methods .............................................................. 47
Treatment quality .................................................................................... 48
Prices of the dialysis services .................................................................. 49
Conclusions ............................................................................................. 50
Appendices .............................................................................................. 52
Bibliography ............................................................................................. 76
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List of �igures
Figure 1. Strati�ication of CKD partients by renal and cardio-vascular risk according to eGFR and proteinuria categories ................................................................................ 13
Figure 2. The distribution within the eGFR categories (G1-G5) of the Romanian and the NHANES cohort ................................................................................................................ 13
Figure 3. The distribution of the CKD categories within the Romanian and NHANES cohorts ......................................................................................................................................... 14
Figure 4. The distribution within the proteinuria categories in the Romanian and NHANES cohorts........................................................................................................................... 14
Figure 5. The distribution of risk groups in the Romanian and NHANES cohorts .................................................................................................................................................................. 15
Figure 6. The prevalence of the main comorbidities requiring hospital admittance (CKD – Chronic kidney disease, DM – diabetes mellitus) ......................................... 16
Figure 7. Number of patients treated by hemodialysis (HD), peritoneal dialysis (PD) and renal transplantation (RTx) in 2012 and 2013 in Romania ........................ 19
Figure 8. Estimated number of RRT patients in Romania (per million inhabitants).............................................................................................................................................................. 19
Figura 9. Prevalent dialysis patients in Romania (numbers, 1995-2013) .................................................................................................................................................................................. 20
Figure 10. The rate of increase in prevalent dialysis patients in Romania (2009-2012; in percentage as compared to the previous year) ................................................. 20
Figure 11. Dialysis patients in Romania (2004-2013) and in Europe (2010) (per million inhabitants - pmi) ........................................................................................................... 21
Figure 12. Estimated trends in prevalent patients number and in the rate of increase (percent of the previous year) in Romania 2009-2015 ....................................... 21
Figure 13. Estimated prevalence and incidence of dialysis patients in Romania (pmi - per million inhabitants) .................................................................................................... 22
Figure 14. Estimated number of incident and prevalent hemodialysis (HD) patients in Romania.................................................................................................................................. 23
Figure 15. Estimation of prevalent peritoneal dialysis (PD) patients’ number in Romania ................................................................................................................................................24
Figure 16. The proportions of patients treated by peritoneal dialysis (PD) and of those treated by private dialysis providers in Romania ...............................................24
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Figure 17. Trends in dialysis methods usage in Romania (incident patients; HD – hemodialysis; DP – peritoneal dialysis) ..............................................................................25
Figure 18. The proportions of patients treated by various RRT methods in Romania (prevalent patients on 31.12.2012; N=10,470; prevalent patients on 31.12.2013; N=11,169; DPA – automated peritoneal dialysis; DPCA – continuous peritoneal dialysis; HDF – hemodia�iltration; HD- hemodialysis) ...........................26
Figure 19. Incident patients on day 1 in renal replacement therapy in the period 2007-2015 and the percentage of non-preemptive transplant patients) .............27
Figure 20. Origin of kidney grafts for non-preemptive transplantation in 2013 and 2014 ................................................................................................................................................27
Figure 21. Rate of variation (2013/2014; %) in RRT prevalent patients number ..................................................................................................................................................................28
Figure 22. Distribution of dialysis patients in Romania at 31.12.2012 (up) and 31.12.2011 (down). The counties having within both years the lowest prevalence rates in the country have been highlighted. Data are expressed in number of patients treated per million inhabitants (pmi). The color scale is de�ined by the national median and by the quartiles. .....................................................................................................................................................................................29
Figure 23. Dialysis prevalent and incident patients (per 1 million inhabitants) in Romanian counties (in descending order) .........................................................................30
Figure 24. The distribution of incident patients in peritoneal dialysis (PD - up) and in non-preemptive renal transplantation (RTx - down). The renal transplantation centers and the areas prescribing RTx and HD (blue), PD and HD (green) and exclusively HD (red) are highlighted. ....................................31
Figure 25. Standardized mortality ratio (SMR) in hemodialysis patients by provider (2012) ..........................................................................................................................................33
Figure 26. Standardized mortality ratio (SMR) in hemodialysis patients by provider (2013) ..........................................................................................................................................33
Figure 27. Cumulative survival rated of patients starting renal transplantation (TR), hemodialysis (HD) or peritoneal dialysis (DD) in 2008-2011 in Romania.................................................................................................................................................................................................................................................................................35
Figure 28. Incident RRT patients in the Europe in 2011 (EDTA-ERA Registry 2011) ...........................................................................................................................................................36
Figure 29. The proportion of RRT incident patients with ages above 65 years of age in Romania (RRR, USA (USRDS) and Europe (EDTA-ERA Registry) .................36
Figure 30. Incident RRT patients in 2011 (pmi) (international comparison) ...........................................................................................................................................................................37
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Figure 31. Variation 2011/2006 (%) in incident RRT patients number (pmi) (international comparison) ...............................................................................................................37
Figure 32. The proportion of diabetic patients incident in RRT in 2011 (international comparison). ..........................................................................................................................38
Figure 33. Variation 2011/2006 (%) of the proportion of diabetic patients incident in RRT (international comparison) ..................................................................................38
Figure 34. The proportions (%) of prevalent patients treated by hemodialysis (HD), peritoneal dialysis (DP) and renal transplantation (TR) in Europe and Romania .............................................................................................................................................................................................................................39
Figure 35. The proportions (%) of incident patients treated by hemodialysis (HD), peritoneal dialysis (DP) and renal transplantation (TR) in Europe and Romania .............................................................................................................................................................................................................................39
Figure 36. Patients prevalent on RRT at 31st of December 2011 (pmi) (international comparison) NB. In 2013, in Romania there were 732 patients treated pmi...........................................................................................................................................................................................................................................................40
Figure 37. Variation 2011/2006 (%) in number prevalent patients undergoing RRT (international comparison) ................................................................................................40
Figure 38. Variation 2011/2006 (%) in prevalent RRT patients number in Europe and in Romania (HD – hemodialysis; DP – peritoneal dialysis; TR – renal transplantation) ...............................................................................................................................................................................41
Figure 39. Trends of the use of renal replacement therapy methods in Europe and in Romania (variance 2011/2006, in percentage).......................................................41
Figure 40. Unadjusted survival rates of incident dialysis patients in the period 2006-2010 in Europe (EDTA-ERA) and in Romania (all differences are signi�icant) .....................................................................................................................................................................................................................................42
Figure 41. The ratio of the dialysis service providers on 31.12.2013 (percentage from the total number of prevalent patients) ....................................................................43
Figure 42. Variation in prevalent patients’ number 2013/2013 (%) by dialysis service provider ..................................................................................................................................43
Figure 43. The proportion of dialysis patients treated in the public sector (%) ......................................................................................................................................................................44
Figure 44. The proportion of PD patients by dialysis providers (percentage of the total number of dialysis patients) .......................................................................................44
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Figure 45. The trends in peritoneal dialysis usage by dialysis providers in Romania (PD prevalent patients 2012/2006 in percentage) ...................................................45
Figure 46. Dialysis centers in Romania (2004-2012) ..........................................................................................................................................................................................................................46
Figure 47. The number of patients bene�iting from the dialysis program, the program budget (hundreds of thousands of RON) and the costs per patient (Euro, at the reference NBR currency exchange rate for that year) ...............................................................................................................................................................................................46
Figure 48. RRT methods in Romania (2012) and in Europe (EDTA-ERA). Estimated costs of the replacement therapy for one patient/year (HD – hemodialysis, DP – peritoneal dialysis; TR – renal transplantation) ................................................................................................................................................................................47
Figure 49. Modeling the economic impact of the use of PD in 20% of the incident patients (Model DP) compared to the current situation(over 80% hemodialysis – Model HD) and the increase of renal transplantations to 30% (Model TR). Five years after the introduction of the PD model, the estimated savings compared to the current situation would allow including all incident patients without an increase in the budget. .............47
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List of tables
Table I. Prevalence of CKD within the adult populati on of Romania 14
Table II. Esti mati on regarding the prevalence of CKD risk groups within the adult populati on of Romania 15
Table III. Comorbiditi es requiring hospital admitt ance 16
Table IV. Characteristi cs of the incident pati ents of the 1st day of dialysis within the period 2007-2013 17
TableV. Characteristi cs of non-preemepti ve transplant pati ents in 2013 17
Table VI. The fi rst 15 centers by the number of newly included hemodialysis pati ents 18
Table VII. The fi rst 15 centers by the number of newly included peritoneal dialysis pati ents 18
Table VIII. Ways of prescribing renal replacement therapy methods in the counti es of Romania (2012) 31
Table IX. Dialysis treatment in children in the period 2007-2013 32
TableX. Adjusted* survival rates (%) by renal replacement therapy methods 35
Table XI. Factors determining the survival of the pati ents treated by renal replacement therapy methods 35
Table XII. Unadjusted survival rate at 90 days, 1 year and 2 years for the cohort 2006-2010, incident dialysis pati ents in Europe and Romania 42
Table XIII. Dialysis centers, prevalent pati ents by provider in Romania (2012/2011) 43
Table XIV. Weighted infl uences on the expenses of the Program for dialysis renal replacement 49
Table XV. The characteristi cs of the pati ents investi gated for the survival analysis 53
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List of appendices
Appendix 1. The method for the calculati on of the standardized mortality rati o .......................................................................................................................... 52
Appendix 2. The method for the calculati on of the survival rates .................................................................................................................................................. 53
Appendix 3. Dialysis centers, machines and pati ents treated on a machine in the counti es of Romania in 2012, 2013 and variance 2013/2012 (in percentage) ................................................................................................................................................................................................................................. 54
Appendix 4. Dialysis pati ents registered on 31.12.2012 and 31.12.2013 in the counti es of Romania and the variance 2013/2012 (in percentage) ................. 56
Appendix 5. Pati ents newly-included in the haemodialysis (HD), peritoneal dialysis (PD), non-preempti ve renal transplantati on (RT) and the number of deaths in 2013 in the counti es of Romania ............................................................................................................................................................ 58
Appendix 6. Prevalent pati ents in the dialysis centers in Romania on 31.12.2011 vs. 31.12.2010 and the variance 2012/2011 in percentage (in the alphabeti cal order of the counti es) ...................................................................................................................................................................................... 60
Appendix 7. Prevalent and incident dialysis pati ents, non-preempti ve transplanted or deceased pati ents in dialysis centers in Romania in 2013(in the alphabeti cal order of the counti es) ...................................................................................................................................................................................... 66
Appendix 8. Haemodialysis centers ordered increasingly by the standardized mortality rati o (SMR) .......................................................................................... 71
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Acknowledgements
Physicians 1. Turkes Ablachim 2. Constanţa Andone 3. Carina Daniela Andrei 4. Mihaela Anghel 5. Daniela Anghel 6. Carmen Elena Anton 7. Luminiţa Ardelean 8. Mihai Ardeleanu 9. Gabriel Bako 10. Mihaela Bălgradean 11. Anca Barbu 12. Cezarina Bejan 13. Marilena Teti c 14. Aurel Bizo 15. Anca Blaga 16. Ioan Boca 17. Eniko Bodurian 18. Gheorghe Boţan 19. Lavinia Brătescu 20. Constanti n Bulancea 21. Mirinela Buruiană 22. Viorica Butnaru 23. Maia Caraman 24. Nicoleta Carastoian 25. Cecilia Jitea 26. Adela Chindriş 27. Bogdan Cîmpineanu 28. Iuliana Ciocănea 29. Daniela Ciortea 30. Cezar Lucian Cocerjin 31. Elisaveta Codoşpan 32. Adrian Covic 33. Maria Covic 34. Olimpia Creţu
35. Constanti n Cruceru 36. Luminiţa Damian 37. Dionisie Dubinciuc 38. Sergiu Dumitrache 39. Hortensia Viorica Epure 40. Lidia Florescu 41. Gabriela Maria Fociuc 42. Nicoleta Irina Fofi că 43. Valenti na Georgescu 44. Ivona Georgescu 45. Adrian Ghenu 46. Mirela Gherman Căprioară 47. Mirela Liana Gliga 48. Ovidiu Golea 49. Sabina Grigorescu 50. Monica Simona Heţeganu 51. Mariana Iacob 52. Ioana Iacob 53. Ion Iancu 54. Rodica Ilieş 55. Ligia Iosub 56. Zsofi a Rozalia Ivacson 57. Christi an Klein 58. Raluca Ungureanu Lie 59. Doriana Lucaciu 60. Radu Macavei 61. Florin Mărgineanu 62. Simona Marian 63. Adriana Marinescu 64. Ioana Diana Mariş 65. Beatrice Marusceac 66. Sorina Masek 67. Marilena Micu 68. Ileana Mihăilescu
69. Eugen Moţa 70. Dan Munteanu 71. Mihaela Munteanu 72. Ioana Nicoleta Nicolae 73. Marcel Palamar 74. Radu Viorel Pâtea 75. Ioan Mihai Paţiu 76. Marilena Piper 77. Mariana Pop 78. Luminiţa Popa 79. Marcela Pravăţ 80. Daniela Pricop 81. Monica Radu 82. Mihai Raicu 83. Eugenia Răilean 84. Violeta Roman 85. Leonard Roşu 86. Mihaela Roşu 87. Cornel Rusan 88. Oana Schiller 89. Cristi an Serafi nceanu 90. Aurelian Simionescu 91. Petronela Şodolescu 92. Costel Spânu 93. Roxana Dorina Stavăr 94. Ioana Suciu 95. Dorina Tacu 96. Cătălin Tacu 97. Mircea Ţandrău 98. Cristi na Teodoru 99. Delia Timoft e 100. Daniela Elena Tir 101. Camelia Totolici 102. Carmen Turcea
103. Liliana Tuţă 104. Cristi na Văduva 105. Peter Varga 106. Mariana Vasilescu 107. Adina Monica Vereş 108. Gabriela Voicu 109. Mihai Voiculescu 110. Carmen Volovăţ 111. Diana Zilişteanu 112. Adrian Zugravu 113. Radu Drăgulete 114. Adriana Buhai 115. Tati ana Șuiaga 116. Mirela Modâlcă 117. Cristi ana David 118. Elena Bălțatu 119. Claudia Cusai 120. Ana Maria Dominte 121. Suzana Anca Berca 122. Diana Copăceanu 123. Andreea Costea 124. Mihaela Iavorenciuc 125. Carmen Denise Căldăraru 126. Adrian-Bogdan Ghigolea 127. Oana Sklerniacof
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1. Cati Aursăchioaie2. Gaspar Balazs3. Zoltan Barabas4. Mariana Becheanu5. Mirela Beldean6. Mihaela Beldiman7. Marcela Berar8. Mariana Bîrsan9. Istvan Blenyesi10. Georgeta Blidariu11. Ilie Blotor12. Marian Boboc13. Maria Boeru14. Cristi ana Bojica15. Adrian Bosie16. Marin Brașoveanu17. Ioana Breaza18. Ana Maria Igna19. Cristi na Bursuc20. Narcis Buturugă21. Oti lia Carteleanu22. Nicoleta Stoica23. Veronica Călin24. Cipriana Cherecheș25. Beniamin Chifor26. Ionela Chirigiu27. Teodora Condriuc28. Romulus Corban29. Lucian Costăchescu30. Valerica Crîșmaru31. Georgiana Cutocheraș32. Loredana Danciu33. George Dănăilă34. Stela Dănulescu
35. Doru Deju36. Adrian Dobrițoiu37. Olga Dragula38. Gina Dumbravă39. Elena Durubală40. Camelia Epure41. Mirela Faur42. Livia Flore43. Emilian Floroaia44. Margareta Grădilă45. Gabriela Ioniță46. Delia Iordache47. Elena Lazăr48. Elena Lulciuc49. Sergiu Lupulescu50. Anca Maczo51. Gabriela Maft ei52. Aurel Marian53. Elena Marin54. Sorina Matei55. Amalia Mihance56. Paula Mîndreanu57. Elena Munteanu58. Sanda Nica59. Luminiţa Nițu60. Mirela Olaru61. Monica Olăroiu62. Răducu Olteanu63. Claudiu Oțetea64. Elena Pais65. Ionela Palade66. Ionela Pascal67. Irina Pert
68. Monica Crăciun69. Florenti na Petrescu70. Oana Petruț71. Tania Câmpeanu72. Adriana Ploscar73. Veronica Ploștenaru74. Dana Poborena75. Marius Popoacă76. Melania Prioteasa77. Anca Pucerea78. Maricica Radu79. Carmen Raicu80. Liliana Răcoreanu81. Monica Rodina82. Mădălina Rugină83. Anca Rusu84. Angelica Sandu85. Maria Savu86. Ioan Schink87. Florenti na Sebacher88. Bianca Semeniuc89. Dorina Serciu90. Roxana Seserman91. Laura Slabinschi92. Ştefania Stănescu93. Doina Stângă94. Monica Stoica95. Elena Stoina96. Zoe Stroe97. Cristi an Stupinean98. Monica Suciu99. Liliana Şerban100. Armand Ştefănescu
101. Angela Ştirbu102. Mădălina Tene103. Ioana Tipa104. Cristi na Toacă105. Carmen Tonița106. Erika Trif107. Lenuţa Tucă108. Daniela Tudor109. Lucian Tudora110. Georgeta Turc111. Constanti n Vlădescu112. Elena Voiculescu113. Francisc Zabos114. Mihaela Zaraza115. Georgeta Cristi na Niță116. Eugenia Naft an117. Cristi na Tutuianu118. Elena Ilie119. Emilia Chifor120. Alina Bâlcă121. Cristi na Zamora122. Nicoleta Huzum123. Gabriela Moise124. Dana Sabie125. Adriana Cerăceaun126. Elena Anastasiu127. Daniela Duță128. Diana Mocanu129. Violeta Gabor130. Camelia Șendroiu131. Andreea Boțan
Persons in charge with the relati onship with RRR
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Data source
The report regarding the situati on of renal replacement therapy in Romania is based on the data gathered on-line by the Romanian Renal Registry using the Hipocrate IT system, with the parti cipati on of 97% of the existi ng dialysis centers in 2013.
The data regarding the kidney transplantati on in incident dialysis pati ents are received from the dialysis centers, while the data regarding the pre-empti ve kidney transplantati on and the monitoring of the prevalent kidney transplant pati ents are provided by a single transplantati on center from the four existi ng centers. The number of prevalent transplant pati ents on 31.12.2012 and 2013 was provided by the Nati onal Health Insurance House.
Epidemiology of Chronic kidney disease was evaluated using data collected in the Romanian Ministry of Health Program of Health Status Evaluti on in a cohort from Iassy county. The new analyses complete the already published data1,2,3.
REPORT ON THE RENAL REPLACEMENT THERAPY IN ROMANIA 2013
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Proteinuria categories
A1 A2 A3<30mg/day 30 – 300mg/day >300mg/day
Absent 1+ >1+
eGFR categories
G1 >90mL/min
G2 89-60mL/min
G3a 45-59/mL/min
G3b 44-30mL/min
G4 29-15mL/min
G5 <15mL/min
RiskMinimumLowModerateHigh
Figure 2. The distributi on within the eGFR categories (G1-G5) of the Romanian and the NHANES cohort
57.9 %
35.4 %
4 .6 %1.6 % 0.4 % 0.1%
6 .7%
4 5.1% 4 5.3%
7.7%
1.6 % 0.2% 0.1%
9 .7%
0%
10%
20%
30%
4 0%
50%
6 0%
70%
G1 G2 G3a G3b G4 G5 G3-G5
NHANES
Ro
Figure 1. Strati fi cati on of CKD parti ents by renal and cardio-vascular risk according to eGFR and proteinuria categories
Chronic kidney disease
Data source
The database created during the Program of Health Status evaluati on (2007-2008) in the Iași county contained informati on on 176,586 subjects. Data on serum creati nine and the proteinuria were available for 32,174 subjects. Aft er excluding parti cipants with age below 21 years, the fi nal populati on analyzed included 30,068 adults (17% of the evaluated subjects, 4% of the county populati on).
De�initionsCKD diagnosis, eGFR and proteinuria categories and the strati fi cati on by risk were defi ned according to KDIGO 20124 (Figure 1). Because proteinuria was qualitati vely measured using strips or quanti tati vely, the results were converted in A1-A3 risk categories as described by KDIGO, and the eGFR was esti mated based on serum creati nine level and CKD-EPI formula.
eGFR categories
The prevalence of G3-G5 CKD stages was lower in the NHANES cohort than in the adult populati on of Romania. The prevalence of persons in G1 was lower, but higher in G2 and G3a categories, in Romania as compared to USA. These diff erences are probably due to the higher prevalence of diabetes in the USA and to a selecti on bias in the Iași cohort, where seems that especially pati ents with comorbiditi es came for evaluati on (Figure 2).
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Proteinuria categories
The distributi on within the proteinuria categories was almost numerical equal in NHANES and Romanian cohorts (Figure 3).
Chronic kidney disease
CKD (defi ned as albuminuria above 30mg/g - A2 or eGFR below 60mL/min -G2+) prevalence in Romania was 13.1%, comparable to reports in the NHANES cohort (11.5%) (Figure 4).
Table I. CKD prevalence CKD in the adult populati on of Romania
CKD category Percentage NumberG1 + A2-A3 0.7% 101.200G2 + A2-A3 2.8% 404.801G3a 7.7% 1,113,202G3b 1.6% 231.315G4 0.2% 28.914G5 0.1% 14.457Total CKD 13.1% 1,893,889On May 31st 2014 the populati on of Romania was of 19,631,292, and the populati on above 24 years of age reached to 14,457,168 inhabitants (INS)
By extrapolati on to the enti re adult populati on of Romania, about 1,900,000 persons are aff ected by Chronic kidney disease, from which 275,000 would require specialized nephrology care (stages 3b-5). (Table I).
Figure 4. The distributi on within the proteinuria categories in the Romanian and NHANES cohorts
Figure 3. The distributi on of the CKD categories within the Romanian and NHANES cohorts
9 3, 2%
5, 4 %1, 3%
9 4 , 9 %
4 , 0% 1, 1%0%
20%
4 0%
6 0%
80%
100%
A1 A2 A3
NHANES
Ro
2, 3% 2, 5%
4 , 6 %
1, 6 %0, 4 %
0, 1%
11, 5%
0, 7%
2, 8%
7, 7%
1, 6 %
0, 2% 0, 1%
13, 1%
0%
2%
4 %
6 %
8%
10%
12%
14 %
NHANES
RO
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Strati�ication by risk
Although the distributi on by eGFR and albuminuria categories diff ered, there were no major diff erences in the distributi on of the two cohorts in the risk groups (Figure 3).
Table II. The esti mated prevalence of CKD risk groups within the Romanian adult populati on
CKD category Percentage NumberMinimum risk 86.9% 12,468,609Low risk 9.2% 1,316,303Medium risk 3.0% 437,177High risk 0.9% 128,385On May 31st 2014 the populati on of Romania was of 19,631,292, and the populati on above 24 years of age reached to 10,490,197 inhabitants
Thus, almost 500,000 Romanian are at medium and high risk and should be cared by the existi ng 300 nephrologists.
A1A2
A3
G1G2
G3aG3b
G4
G5
57.9
34.5
3.6
1.0
0.2
0.1
NHANES
A1A2
A3
0%
5%
10%
15%
G1G2
G3aG3b
G4
G5
45.1%45.3%
6.5%
1.3%
0.2%
0.1%
România
A1A2
A3
G1G2
G3aG3b
G4
G5
57.9
34.5
3.6
1.0
0.2
0.1
NHANES
A1A2
A3
0%
5%
10%
15%
G1G2
G3aG3b
G4
G5
45.1%45.3%
6.5%
1.3%
0.2%
0.1%
România
Figure 5. The distributi on of risk groups in the Romanian and NHANES cohorts
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Comorbidities and CKD
The main comorbiditi es imposing hospital admission were HBP, heart failure and diabetes mellitus. Stroke, as well as death, were twice more common in CKD than in non-CKD persons (Table III).
The need of hospital admission seemed to be less infl uenced by the CKD, even though the average number of admissions was lower in CKD (Table III).
Table III. Comorbiditi es imposing hospital admission
CKD Non-CKD
Hospital admissions(for 100 persons-years)
6.4 10.5
Comorbidity (% admitt ances)
• HBP 46.1% 29.3%• Heart failure 19.3% 11.1%• Stroke 8.6% 4.3%• Ischemic heart disease 7.5% 4.2%Deaths (for 100 persons-years) 1.41 0.70
According to causes of admission, the esti mated prevalence of diabetes mellitus, cardiovascular diseases, and CKD were 9%, 30% and 10%, respectti vely. All these pathology categories were strongly related (Figure 6).
Figure 6. The prevalence of the main comorbiditi es requiring hospital admitt ance (CKD – Chronic kidney disease, DM – diabetes mellitus)
• The Chronic kidney disease has a higher prevalence in Romania that in the NHANES cohort: 13.1% vs. 11.5%; the esti mated number of adult persons with CKD in Romania is about 1,900,000.
• Since the number of CKD pati ents with medium-high risk is 565,000, a nephrologist should have under care 1,900 pati ents (approximately 20 visits/day).
• CKD pati ents suff er more oft en from diabetes mellitus, HBP, stroke and heart failure, and their risk of death is twice higher. As a result, the CKD care should be multi disciplinary (diabetology, cardiology and nephrology).
• The medical assistance is mainly provided in hospital (over a quarter of the pa-ti ents are admitt ed into hospital), regardless of the state of the kidney, and the CKD pati ents have almost twice as many hospital admitt ances.
• Thus, multi disciplinary CKD medical care programs promoti ng ambulatory care are needed.
17
Dialysis incident pati ents were mainly men, with a mean age of 62.6 years (42% above 65 years).
The most frequent primary kidney disease was diabeti c nephropathy (14.7%), but in more than a third of pati ents (37.7%) the primary renal disease was not known. This high proporti on of undiagnosed cases highlights the late CKD identi fi cati on imposing emergency dialysis initi ati on (Table IV).
Non-preempti ve transplanted pati ents are mostly men and are younger than incident dialysis pati ents. The most frequent primary kidney disease was glomerulonephriti s (45.9%) and was unknown in more than a third of the cases (36.2%) (Table V).
• The incident pati ents’ characteristi cs are changing: the proporti on of the diabeti c pati ents above 65 years is increasing (42% and 15%), which would imply additi onal resources for care.
• As there are no effi cient programs addressing CKD before the renal replacement therapy initi ati on, the dialysis is initi ated under emergency conditi on with higher morbidity and mortality rates and higher costs, and primary renal disease is barely diagnosed.
Table IV. Characteristi cs of incident pati ents in the 1st day of dialysis within the period 2007-2013
2007 2008 2009 2010 2011 2012 2013Centers (number) 75 85 102 131 148* 137* 138*Reporti ng centers (%) 100 100 98 90 92 96 97Incident pati ents day 1
Number 1,910 2,036 2,377 2,662 2,987 3,428 3,063Sex (B%) 58.8 57.8 57.7 57.5 57.6 57.8 56.7Average age (years) 58.1 58,.3 60.5 61.2 62.0 62.6 62.6≥ 65 years (%) 34 37 39 39 41 43 42Primary kidney disease
Glomerulonephriti s (%) 17.1 16.2 13.5 13.9 13.6 13.7 12.6Intersti ti al nephriti s (%) 12.4 11.5 11.4 11.2 11.3 11.3 10.0Hereditary-congenital nephropathies (%)
5.7 5.8 5.1 4.6 5.3 6.6 4.4
Diabetes mellitus (%) 11.7 19.9 18.7 13.3 14.8 15.7 14.7Kidney vascular disease (%) 6.5 11.8 6.2 6.3 14.5 15.4 9.9Other (%) 15.5 9.4 6.4 7.4 5.5 6.4 10.7Unknown (%) 31.1 25.4 38.7 43.3 35.0 30.9 37.7Replacement therapy method at the beginningHD (%) 82.3 82.0 83.6 93.5 93.8 95.1 95.0DP (%) 17.7 18.0 16.4 6.5 6.2 4.9 5.0
Table V. Characteristi cs of incident non-preemepti ve transplant pati ents in 2013
Sex (B%) 67.9Age
average (years) 42.1≥ 65 years (%) 1.4Primary kidney disease
Glomerular nephriti s (%) 45.9Intersti ti al nephriti s (%) 2.8Hereditary-congenital (%) 5.1Diabetes (%) 2.2Renal vascular diseases (%) 2.8Other (%) 5.0Unknown (%) 36.2
Incident RRT patients
18
Table VI. The fi rst 15 centers by the number of newly included hemodialysis pati ents
Center Newly-included pati ents
“Dr. C. I. Parhon” Clinical Hospital Iasi 261
“Dr. Carol Davila” Clinical Nephrology Hospi-tal – Bucharest
172
University Emergency Hospital Bucharest 133
“Sf. Ioan cel Nou” County Hospital Suceava 132
“Sf. Ioan” Clinical Hospital Bucharest 110
Craiova County Emergency Hospital 103
Constanta County Emergency Hospital 92
Cluj County Hospital 76
Arad County Hospital 74
Prahova County Hospital 67
Sibiu County Hospital 67
Timis County Hospital 62
Brasov County Emergency Hospital 61
Dambovita County Hospital Targoviste 61
Hunedoara County - Deva 56
Total 1.527** 58% of total number of newly included pati ents
Most of incident pati ents were included in the hospital centers (“CI Parhon” Iași, “Dr Carol Davila” and the University Emergency Hospital Bucharest for hemodialysis, and “Dr Carol Davila”, “Fundeni” Insti tute and “Sf Apostol Andrei” Galați, for peritoneal dialysis) (Tabelul VI, Tabelul VII).
Table VII. The fi rst 15 centers by the number of newly included peritoneal dialysis pati ents
Center Newly-
included pati ents
“Dr. Carol Davila” Clinical Nephrology Hospital – Bucharest
16
“Fundeni” Clinical Insti tute 14
“Sf. Ap. Andrei” County Hospital - Galati 12
IHS - Buzau 10
Bacau County Hospital 10
Braila County Hospital 8
Craiova County Hospital 5
Renamed Nefrodial - Oradea 5
“N. Paulescu” Insti tute Bucharest 5
Fresenius NephroCare - „CI Parhon” Iasi 5
IHS “Sf. Ioan” Bucharest 4
IHS - Ramnicu Valcea 4
University Emergency Hospital Bucharest 3
Teleorman County Hospital – Alexandria 3
“Sf. Pantelimon” County Hospital - Focsani 3
Total 107**69% of total number of newly included pati ents
19
9 , 551
9 19
2, 4 57
10, 322
854
2, 723
-
2, 000
4 , 000
6 , 000
8, 000
10, 000
12, 000
HD DP RTx
2012
2013
+ 8%
- 7%
+ 11%
The total number of pati ents undergoing renal replacement therapy on 31.12.2013 was 13,899, an 8% increase compared to the year 2012. The increase was especially caused by transplant (+11%) and the hemodialysis pati ents (+8%), while peritoneal dialysis decreased by 7% (Figure 7).
The number of RRT pati ents per million inhabitants reached to 732, increasing, but sti ll below the European average from 2012 (947 RRT pati ents per million inhabitants) (Figure 8). If the current trends are maintained, Romania will reach the average European level of RRT coverage in 2016, when the rate of increase in pati ent number it is expected to decrease.
• Renal replacement therapy coverage in Romania approaches the European average that it shall reach in 2016.
Patients under treatment (prevalent)
Figure 7. Number of pati ents treated by hemodialysis (HD), peritoneal dialysis (PD) and renal transplantati on (RTx) in 2012 and 2013 in Romania
Figure 8. Esti mated number of RRT pati ents in Romania (per million inhabitants)
6 80732
8899 4 0
9 9 1104 2
109 4119 6
0
200
4 00
6 00
800
1000
1200
14 00
2012 2013 2014 2015 2016 2017 2018 2020
RRT
patie
nts
per m
illio
n po
pula
tion
ED TA- ERA 2012
20
39 105 235 324 4 16 516 770 876 1100 104 8 114 5 1255 139 9 1385 116 9 1029 1007 9 19 8541, 16 4 1, 4 86 1, 9 6 02, 39 1 2, 6 4 8 3, 04 9
3, 502 4 , 09 84 , 700 4 , 9 86 5, 138 5, 4 6 0 5, 587
6 , 9 867, 255
8, 06 88, 74 8
9 , 55110, 322
0
2, 000
4 , 000
6 , 000
8, 000
10, 000
12, 000
19 9 5 19 9 6 19 9 7 19 9 8 19 9 9 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Pr
eeva
lent
dia
lysi
s pati
ents
(num
ber)
DP HD
1.203 1.59 1 2.19 5 2.7153.06 4 3.56 5
4 .2724 .9 74
5.800 6 .034 6 .283 6 .7156 .9 86
8.371 8.4 249 .09 7 9 .755
10.4 70
Total
11.176
6 , 4 %
8, 0%
7, 2% 7, 3%
6 , 7%
3
4
5
6
7
8
9
2009 2010 2011 2012 2013
roiretna luna ed af etnecor
P
Figure 10. The rate of increase in prevalent dialysis pati ents in Romania (2009-2012; in percentage as
compared to the previous year)
Dialysis patients
Since 1996 the total number of pati ents prevalent on dialysis constantly increased, exceeding 11,000 in 2013 (Figure 9).
The rate of increase was not constant: the initi al fast increase (1996-2000; +32.7%/year) slowed down (2001-2003 and 2004-2006), and fi nally the rate increased again to 7.3%/year in 2007-2013 (Figure 9).
However, the rate of increase decreased to 6.7% in 2013, below the average of the last 5 years (Figure 10).
Figura 9. Prevalent dialysis pati ents in Romania (numbers, 1995-2013)
21
The number of dialysis pati ents depends on the:
• Prevalence of Chronic kidney disease;• Resources allocated for dialysis, i.e. number of
dialysis faciliti es and reimbursement by Health Insurance House;
• Effi ciency of the transplantati on program.
Since there are no reasons to believe that CKD prevalence diff ers in Romania from Europe, the prevalence of dialysis pati ents should be similar. Therefore, the number of dialysis pati ents shall increase gradually in Romania unti l it reaches the European average. In 2013 there were 666 dialysis pati ents per million inhabitants (pmi) in Romania, compared to the European average of 883, which corresponds to a total number of dialysis pati ents of 17,660 in Romania (Figure 11). Thus, the number of Romanian dialysis pati ents shall conti nue to grow by more than 5% each year unti l it reaches 18,000, depending on the Health Insurance House funding.
The lower than 7% rate of increase in prevalent pati ents observed in 2013 is probably due both to the progressive coverage of the dialysis need of the populati on and to the more acti ve transplant program. As the number of prevalent pati ents (an indicator of the dialysis coverage) increases, the rate of increase in the number of pati ents has a decreasing trend (Figure 12).
Figure 11. Dialysis pati ents in Romania (2004-2013) and in Europe (2010) (per million inhabitants - pmi)
Figure 12. Esti mated trends in prevalent pati ents number and in the rate of increase (percent of the previous year) in Romania 2009-2015
318 331 3534 20
4 9 8 50754 7 582 59 2
6 6 6
883
0
200
4 00
6 00
800
1000
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 EDTA( 2010)
Prev
alen
t dia
lysi
s pa
tient
s (p
mi)
84 249 , 087
9 , 75510, 4 70
11, 17611, 84 8
12, 537
6 .4
8.0
7.27.3
6 .7
7.1 7.1
6
6 .5
7
7.5
8
8.5
9
7500
10000
12500
15000
2009 2010 2011 2012 2013 2014 2015
Rate
of i
ncre
ase
(%)
N
umbe
r of p
reva
lent
pati
ents
Number of prevalent patients Rate of increase (%)
22
Figure 13. Esti mated prevalence and incidence of dialysis pati ents in Romania (pmi - per million inhabitants)
The model in Figure 14 suggests that, if the current trends are maintained:
• The esti mated rate of increase in prevalent pati ents number for 2014-2015 is 7%;
• In 2014, 11,600 pati ents will be treated by dialysis, and in 2015, 12,200.
• In 2014, 3,100 new pati ents will be included in dialysis, and in 2015, 3,400.
8, 371 8, 4 249 , 09 7
9 , 75510, 4 70
11, 17611, 6 31
12, 22612, 821
13, 4 1614 , 010
14 , 6 0515, 200
2, 017 2, 24 8 2, 4 88 2, 4 9 8 2, 86 4 2, 79 9 3, 06 2 3, 39 5 3, 589 3, 557 3, 6 14 3, 886 4 , 051
4 19 4 214 55
4 88524
559582
6 116 4 1
6 71701
73076 0
0
200
4 00
6 00
800
0
5, 000
10, 000
15, 000
20, 000
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Inci
dent
dia
lysi
s pa
tient
s (n
umbe
r)
Prev
alen
t dia
lysi
s pa
tient
s (n
umbe
r)
Prevalent patients (number) Incident patients Prevalent patients (pmpi)
23
Hemodialysis patients
The number of prevalent hemodialysis pati ents steadily increased, faster within the last 5 years. If the current trends are maintained, by the end of 2014 11,000 pati ents shall be treated by hemodialysis, and by the end of 2015, 11.800 (Figure 14).
The number of incident hemodialysis pati ents doubled from 2007 to 2013. The predicti on for 2014 and 2015 is of 3,400 and 3,600 incident hemodialysis pati ents (Figure 14).
If the current trends are maintained:
• by the end of 2014 there will be 11,000 pati ents treated by hemodialysis, and by the end of 2015, 11.800.
• In 2014 and 2015 there will be 3,400 and respecti vely 3,600 incident hemodialysis pati ents.
1.9 1 2.04 2.38 2.6 6 2.9 8 3.4 42.6 4
3.38 3.58 3.78 3.9 6 4 .11 4 .26 4 .4 25.59
6 .9 9 7.268.07
8.759 .55
10.3211.05
11.7912.54
13.2014 .01
14 .7515.4 9
0.00
4 .00
8.00
12.00
16 .00
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Prev
alen
t HD
patie
nts (
thou
sand
s)
Figure 14. Esti mated number of incident and prevalent hemodialysis (HD) pati ents in Romania
24
Peritoneal dialysis patients
Peritoneal dialysis has a series of advantages, both medical (low pati ent dependence on the dialysis center, bett er preservati on of renal functi on than hemodialysis) and economic (lower therapy cost, which would allow to treat more pati ents with the same budget). Although peritoneal dialysis has few medical contraindicati ons, the proporti on of PD pati ents is decreasing in Romania and worldwide. If the current trend is maintained, peritoneal dialysis shall practi cally disappear in Romania by the year 2020 (Figure 15).
Although the causes of the decrease in peritoneal dialysis usage are less understood, three factors seem relevant:
• Defi cient predialysis CKD care, imposing emergency initi ati on of RRT, not allowing the pati ent to choose in full awareness the most suitable therapy;
• The costs for the initi ati on of peritoneal dialysis therapy are not deducted to the hospitals by the Nati onal Health Insurance House;
• The price diff erence, which is detrimental to peritoneal dialysis and makes it less att racti ve for the private sector than hemodialysis. Thus, in most of the countries with dominant private sector, the use of peritoneal dialysis is decreasing, which was also noti ced in Romania (Figure 16)
Figure 16. The proporti ons of pati ents treated by peritoneal dialysis (PD) and of those treated by private dialysis providers in Romania
1255
139 9 1385
116 9
1029 10079 19
854780
6 5256 2
5034 25
33024 3
R² = 0.9 7
0
200
4 00
6 00
800
1000
1200
14 00
16 00
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Prev
alen
t PD
patie
nts (
num
ber)
Figure 15. Esti mati on of prevalent peritoneal dialysis (PD) pati ents’ number in Romania
9 5%87%
30%
16 % 12% 12% 11%20% 17% 14 % 11% 10% 9 % 8%0%
20%
4 0%
6 0%
80%
100%
2007 2008 2009 2010 2011 2012 2013
Patients treated by private providers ( % ) PD patients ( % )
25
Although CKD evoluti on is predictable, which would allow preparing the pati ents in ti me for RRT initi ati on, including appropriate educati on, in Romania there are no programs addressing predialysis CKD care. That is why renal replacement therapy is frequently initi ated in an unplanned manner, and the pati ents have not the possibility to choose in full awareness their best suited method of therapy. Accordingly, developing programs of predialysis CKD care with an educati onal component would also allow reversing the descending trend in peritoneal dialysis usage.
On the other hand, the costs of peritoneal dialysis were more aff ected by the recent increase of the VAT tax, of the currency exchange rate and by the changes in the medicine price calculati on, not menti oning the more costly newly introduced peritoneal dialysis soluti ons than the costs of hemodialysis (24% vs. 13%). Accordingly, as peritoneal dialysis is economically less att racti ve then hemodialysis for private providers, its usage will be restrained.
Figure 17. Trends in dialysis methods usage in Romania (incident pati ents; HD – hemodialysis; DP – peritoneal dialysis)
• If the programs for re-establishing the use of PD are successful, by the end of the years 2014 and 2015 there will be 800-900 pati ents treated by PD, and 100-150 pati ents shall be included in the treatment in the years 2014 and 2015 (Figure 18).
1, 572 1, 6 6 91, 9 88
2, 4 882, 801
3, 26 9
2, 6 4 4
3, 3803, 6 38
338 36 7 39 0174 183 174 155 9 1 34
R² = 0.89 15R² = 0.84 4 3
0
500
1, 000
1, 500
2, 000
2, 500
3, 000
3, 500
4 , 000
2007 2008 2009 2010 2011 2012 2013 2014 2015In
cide
nt p
atien
ts (n
umbe
r)
HD DP
26
Figure 18. The proporti ons of pati ents treated by various RRT methods in Romania (prevalent pati ents on 31.12.2012; N=10,470; prevalent pati ents on 31.12.2013;
N=11,169; DPA – automated peritoneal dialysis; DPCA – conti nuous peritoneal dialysis; HDF – hemodiafi ltrati on; HD- hemodialysis)
Patients treated by other dialysis methods
Hemodiafi ltrati on (HDF) and automated peritoneal dialysis (APD) are conditi onally accepted by the NHIH for reimbursement up to 7-10% of prevalent pati ents, due to their higher costs than those of the conventi onal therapy. Their use was not widespread, as they are prescribed to 6.4% and 1.4% of the HD and DP prevalent pati ents, respecti vely (Figure 18).
However, by changing the eligibility criteria for pati ents accepted by NHIH, i.e., young pati ents with no transplantati on perspecti ve for HDF, and raising the limit for APD to allow young pati ents having a high transplantati on probability to be treated, would allow a bett er allocati on of the resources.
• Hemodiafi ltrati on and automated peritoneal dialysis treatments are prescribed within the limits accepted by NHIH.
• Changing the eligibility criteria for these treatments would allow a bett er allocati on of the resources.
HD87,2%
HD86,1%
HDF4,0%
HDF6,2%
DPCA7,8%
DPCA6,2%
DPA 1,0% DPA 1,4%
75%
80%
85%
9 0%
9 5%
100%
2012 2013
DPA
DPCA
HDF
HD
27
Transplant patients
As compared to dialysis, renal transplantati on has medical and economic advantages, but is less used in Romania. Although the number of graft s has conti nuously increased within the last 3 years, only 7% of incident RRT pati ents were non-preempti vely transplanted in 2013 (Figure 19).
However, data are not accurate enough, since they are based on dialysis centers reports and include only non-preempti ve transplants, as a functi onal transplant registry does not exist in Romania. Moreover, as there are no follow-up data in transplanted pati ents, the real contributi on of transplant to the renal replacement therapy can hardly be assessed.
Most of the graft s came from deceased donors (56%), showing an increase compared to 2012 (Figure 20).
• The number of renal transplants increased, the graft s from deceased donors are predominant, but transplantati on sti ll contributes to a lower proporti on to RRT (7% of the incident pati ents).
• Although 230 and 275 non-preempti ve trans-plants are esti mated for 2014 and 2015, at least 400 should be fi nanced to help transplantati on eff ecti vely contribute to RRT in Romania.
• In order to obtain accurate data on transplanted pati ents, mandatory reporti ng of the transplant pati ents to the Romanian Renal Registry should be introduced.
Figure 19. Incident pati ents on day 1 in renal replacement therapy in the period 2007-2015 and the percentage of non-preempti ve transplant pati ents)
Figure 20. Origin of kidney graft s for non-preempti ve transplantati on in 2013 and 2014
1, 9 33 2, 0732, 4 21
2, 6 81
3, 1583, 59 1
3, 017
3, 7003, 9 4 6
1.2%1.8% 1.8%
0.7%
5.5%
4 .1%7.2%
6 .2%7.0%
R² = 0.7781
0
500
1, 000
1, 500
2, 000
2, 500
3, 000
3, 500
4 , 000
4 , 500
0.0%
2.0%
4 .0%
6 .0%
8.0%
10.0%
12.0%
2007 2008 2009 2010 2011 2012 2013 2014 2015
Inci
dent
RRT
pat
ient
s (n
umbe
r)
Non
-pre
empt
ive
tran
spla
nts
(%)
-
Incident RRT patients Non-preemptive transplants
28 22.5
12.7
53 56
16 18.8
0%
25%
50%
75%
100%
2012 2013
Donor of uknow n type
Cadaveric donor
U nrelated living donor
Related living donor
28
NHIH records included 2,723 prevalent transplant pati ents, an 11% increase as compared to 2012. Thus, renal transplantati on recorded the highest increase among renal replacement therapy methods in Romania, exceeding even hemodialysis rate (Figure 21).
• Renal transplantati on had the highest increase among renal replacement therapy methods, as judged by the number of prevalent pati ents.
• It could be esti mated that the number of prevalent transplant pati ents will exceed 3,000 in 2014.
Figure 21. Rate of variati on (2013/2014; %) in RRT prevalent pati ents number
8%
-7%
11%
-8%
-6 %
-4 %
-2%
0%
2%
4 %
6 %
8%
10%
12%
HD D P RTx
Prev
alen
t pati
ents
201
2/20
13 (%
)
29
The territorial coverage with renal replacement therapy is inhomogeneous.
The areas with the highest coverage are around university centers (B, IS, CJ, TM, BH, SB), while Tg Mureș is a remarkable excepti on. Other areas with a good coverage are VN, BR, HD, GJ and MH (due to the higher prevalence of the Balkan en-demic nephropathy in this area).
The center and North-East of Transilvania (CV, MS, SJ, BN), the South of Muntenia (GR, CL, TR, IL), the South of Moldavia (GL) and Oltenia (OT) have the lowest rates of coverage by dialysis. Compared to 2011, the coverage improved in HR and IL, but it dropped in the AR, CS, IL, OT and TR counti es (Figure 22, Figure 23).
The inhomogeneous coverage will perpetuate, as the counti es having the highest prevalence also have the highest number of newly included pati ents, while the counti es with the lowest number of prevalent pati ents reported in 2013 less inci-dent pati ents that the nati onal average (Cl, CV, CS, GL, GR, IL, OT) (Figure 23).
Territorial distribution of RRT methods
Figure 22. Distributi on of dialysis pati ents in Romania at 31.12.2012 (up) and 31.12.2011 (down). The counti es having within both years the lowest prevalence
rates in the country have been highlighted. Data are expressed in number of pati ents treated per million inhabitants (pmi). The color scale is defi ned by
the nati onal median and by the quarti les.
D ialysis p rev alent p atients ( p mi)
2013
2011
D ialysis p rev alent p atients ( p mi)
30
• There are high diff erences in dialysis coverage between the counti es of Romania.
• Since in counti es with university centers there are up to 3 ti mes more dialysis pati ents than the adjoining counti es, a possible explanati on of the inhomogeneous distributi on would be the pati ents’ preference for university centers.
• Several counti es had the lowest prevalence of the dialysis pati ents in consecuti ve years and the lowest number of newly included pati ents in the country (IL, CL, GL, GR, OT, MS, CV). These counti es seem to be the target of the programs addressing Chronic kidney disease. Figure 23. Dialysis prevalent and incident pati ents (per 1 million inhabitants) in
Romanian counti es (in descending order)
26 3274
33236 2372
39 04 03
4 294 334 4 04 4 14 4 1
4 6 14 6 54 6 84 814 864 9 0
505513
52754 955055555857057257457858259 1
6 046 19
6 4 76 4 7
6 736 73
713720
738750750
020
6 34 138
6 676
13481
133129
176121
9 4113
9 280
1169 8
14 04 7
103210
15088
10216 516 6
13780
579 6
227205
10813214 1
19 619 1
375330
151
0 100 200 300 4 00 500 6 00 700 800
GRCLGLCS
MSI L
OTTRCVBNSJ
ARDBPHSM
MMHRTMBZCTAGTLSV
RomâniaBCABDJBVV LBTNTV SHDBHGJCJ
V NBRSBI S
B + I FMH
Prevalent patients
Incident patients
31
Theoreti cally, the renal replacement therapy methods should be complementary used to match the pati ents’ needs. Based on incident pati ents’ allocati on to the RRT methods, in Romania there are four patt ern of prescripti on: HD combined with PD and RT (the most advised), HD combined only with PD (without RT), HD com-bined only with RT (without PD) and exclusive HD (the least advised).
Even though in most of the counti es all three methods are prescribed, in some of them HD is used either only in associati on with PD (South Moldavia, East Muntenia), only with RT (Central Transilvania), and in others HD is prescribed exclusively (Table VIII, Figure 24).
Table VIII. Patt erns of RRT prescripti on in the counti es of Romania (2013)
HD+DP+TR AG, B+IF, BH, BV, CJ, CS, CT, DJ, GL, HD, IS, SB, SM, TM
HD+DP BR, BZ, PH, OT, TR, VNHD+TR AB, AR, BN, HR, MS, NT, SJ, TL, VSHD CL, GR, IL, MM, SV
• The use of renal replacement therapy methods in Romania shows signifi cant area variati ons, refl ecti ng the lack of an unitary practi ce and can infl uence both the evoluti on of the pati ents, and the costs of renal replacement therapy.
Figure 24. The distributi on of incident pati ents in peritoneal dialysis (PD - up) and in non-preempti ve renal transplantati on (RTx - down). The renal transplantati on centers and the areas
prescribing RTx and HD (blue), PD and HD (green) and exclusively HD (red) are highlighted.
2013 PD incident patients (pmi)
2013 RTx incident patients (pmi)
32
In 2013, from the eight pediatric functi oning centers, fi ve are only disconti nuously functi oning.
The total number of children treated by dialysis on 31.12.2013 decreased slightly, reaching to 121.
The number of children incident in dialysis conti nued to have an increasing trend, reaching up to 30 in 2013.
The rati o of pati ents treated by peritoneal dialysis conti nued to decrease down to the maximum level of 30% reached in 2008, reaching to 6.7% in 2013 (Table IX).
• Hemodialysis is the most frequently used RRT method in Romanian children, even though renal replacement therapy in children should be based on peritoneal dialysis and transplantati on.
• There are no available data about transplanta-ti on in children.
The RRT in children
Table IX. Dialysis therapy in children in Romania (2007-2013)
2007 2008 2009 2010 2011 2012 2013
Centers (number)* 7 7 7 8 8 8 8
Prevalent pati ents on 31.12
Number 103 110 119 115 117 123 121
Sex (B%) 53,4 51,8 52,1 53,0 52,6 52,1 52,3
Incident pati ents day 1
Number 35 30 29 28 28 28 30
Sex (B%) 51,3 47,8 54,0 52,4 52,6 51,9 50,0
Dialysis method at RRT ini-ti ati on
- HD (%) 85,4 63,4 68,5 70,4 81,0 84,6 93,3
- DP (%) 14,6 36,6 28,1 29,6 19,0 14,1 6,7
*Five pediatric centers functi on intermitt ently
33
Survival is a syntheti c indicator of the quality of dialysis therapy.
Standardized mortality ratio
Standardized mortality rati o (SMR) is the rati o between the observed and the expected number of deaths. SMRs are used to compare the survival of the pati ents treated in a center (county or network) to the nati onal mortality rate.
This type of analysis allows the comparison between the mortality observed in a populati on or in cohorts specifi cally defi ned, and the nati onal mortality rate assessed in a reference cohort (see Appendix 1).
A SMR strictly above or below 1 describes in percentage how higher or respecti vely lower is the mortality rate versus the nati onal reference rate. SMRs not strictly above or below 1 indicate mortality rates similar cu the nati onal reference rate.
In 2012 and 2013, the mortality rate of hemodialysis pati ents in Romania increased by 27% and 23%. Among the dialysis networks, only the Fresenius recorded in both years a similar mortality rate to the reference, while IHS and Avitum SMRs decreased in 2013 to the reference, aft er being higher in 2012. Public dialysis centers have a double mortality rate compared to the reference level (Figure 25, Figure 26).
Survival of RRT patients
3, 886
9 34 9 56 9 4 5 74 8 6 9 2
8, 16 1
1.07
2.00
1.36 1.30
1.58
1.001.27
0
0.5
1
1.5
2
2.5
0
1, 000
2, 000
3, 000
4 , 000
5, 000
6 , 000
7, 000
8, 000
9 , 000
Fresenius Public IHS D iav erum Av itum Other Romania
SMR
Prev
alen
t HD
patie
nts (
num
ber)
4 132
877 1034 104 3 889 6 9 2
886 5
1.09
2.25
1.091.26 1.19 1.05
1.23
0
0.5
1
1.5
2
2.5
3
0
1, 000
2, 000
3, 000
4 , 000
5, 000
6 , 000
7, 000
8, 000
9 , 000
10, 000
Fresenius Public IHS D iav erum Av itum Other Romania
SMR
Prev
alen
t HD
patie
nts (
num
ber)
Figure 25. Standardized mortality rati o (SMR) in hemodialysis pati ents by provider (2012)
Figure 26. Standardized mortality rati o (SMR) in hemodialysis pati ents by provider (2013)
34
Unfortunately, the standardized mor-tality rati o cannot be used to classify dialysis centers (Appendix 9).
• The HD pati ents’ mortality increased by over 20% in the years 2012, 2013, in Romania as compared to the reference cohort. Since SMR implies adjustment, the increase in age or in the diabetes mellitus proporti on of incident pati ents does not fully account for the rise of the mortality rate. As other comorbiditi es or other factors can be involved, further analyses are needed for clarifi cati on of the observed increase in mortality.
• Public centers had twice higher SMR than the reference rate, probably because they initi ate the treatment (period with the highest death risk) and treat the cases with the highest burden of comorbiditi es.
35
Survival rates
The mean survival of the RRT pati ents starti ng the treatment in 2008-2011 was 3.9 ±0.02 years (adjusted survival rates 1 and 4 years, 86% and 76%) (see Appendix 2 for the calculati on method)5.
Replacement therapy method (HD and PD more than RTx), older age and diabetes mellitus are factors independently associated with the decrease of survival rates (Table X). Young pati ents with a kidney graft , without diabetes mellitus and with glomerulopathies had the best chances of survival (Table XI, Figure 27).
TableX. Adjusted* survival rates (%) by RRT method
1 year
2 years
3 years
4 years
HD 84,8% 79,7% 75,4% 73,6%PD 84,9% 79,7 75,5% 73,6%RTx 97,1% 96,0 95,0% 94,7%RRT 86,1% 81,2% 77,4% 72,5%*by gender, age, primary kidney disease
• RTx pati ents had 5 ti mes more chances of sur-vival than those treated by HD or PD.
• HD and PD had comparable results.
• Diabetes mellitus and increasing age reduced the survival rates by 25% and 3%, respecti vely.
Figure 27. Cumulati ve survival rated of pati ents starti ng renal transplantati on (TR), hemodialysis (HD) or peritoneal dialysis (DD)
in 2008-2011 in Romania
Table XI. Determinants of RRT pati ents’ survival in Romania
Determinants HR PRRT vs RTxHD (vs. RTx)PD (vs. RTx)
5,615,63
<0,001<0,001<0,001
Age 1,03 <0,001Gender: Female vs. Male 0,94 0,5Primary kidney disease (vs. Renal vascular diseases)• Glomerular nephropathies• Tubule-intersti ti al nephriti s• Hereditary nephropathies• Diabeti c nephropathy• Unknown/ Others
0,750,940,621,251,13
<0,001<0,01
0,5<0,001
0,010,1
Surv
ival
Time (months)
36
The most recent reports published by USRDS (2011) and EDTA ERA Registry (2012) were used for comparison7,8.
Incident patients
In 2011, Romania conti nued to be below the European average of the incident pati ents (127 vs. 130 pmi), but had one of the highest rates of increase (66% vs. 6%) (Figure 28, see also Figure 29, Figure 30).Although increasing, the average age of incident pati ents in Romania is lower than in Europe or USA (Figure 29).The proporti on of diabeti c pati ents incident in dialysis in Romania is one of the lowest in Europe. A possible explanati on could be the lack of resources limiti ng the access to treatment of the pati ents with diabetes mellitus and other comorbiditi es. Considering that the rate of increase in dialysis incident pati ents in Romania is one of the highest in Europe, and the average of prevalent pati ents approaches the European average, it would be expected that the rati o of the incident diabeti c pati ents would also increase. However, this is not the case: the rate of increase of in the proporti on of incident diabeti c pati ents in Romania is one of the lowest in Europe). Accordingly, either the prevalence of diabetes is overesti mated in Romania, or the diabeti c predialysis CKD pati ents’ mortality is signifi cantly higher (Figure 32, Figure 33).
Figure 28. Incident RRT pati ents in the Europe in 2011 (EDTA-ERA Registry 2011)
International comparisons
32%
53%4 9 %
39 %
59 %
4 9 %4 2%
59 %
50%
0%
10%
20%
30%
4 0%
50%
6 0%
70%
Romania Europa SU A
Perc
ent
2006 2010 2011
Figure 29. The proporti on of RRT incident pati ents with ages above 65 years of age in Romania (RRR, USA (USRDS) and Europe (EDTA-ERA Registry)
37
Figure 30. Incident RRT pati ents in 2011 (pmi) (internati onal comparison) Figure 31. Variati on 2011/2006 (%) in incident RRT pati ents number (pmi) (internati onal comparison)
4 0
81
9 9
104
104
118
121
121
121
124
130
133
136
139
14 2
14 9
19 0
19 2
19 5
19 8
239
252
288
36 9
Rusia
Finlanda
Scoția
I slanda
Norvegia
Olanda
Suedia
Spania
Danemarca
România
Europa ( ERA-EDTA)
Bosnia
Marea Britanie
Austria
Croația
Franța
Grecia
Belgia, franceză
Belgia, olandeză
Republic Cehă
Portugalia
Turcia
Japonia
SU A
-15
-13
-7
-6
-5
-4
0
0
1
2
2
3
3
4
5
5
6
7
19
31
4 3
50
6 6
Scoția
Austria
Suedia
Finlanda
Spania
Grecia
Bosnia
Croția
SU A
Belgia, olandeză
Danemarca
Belgia, franceză
Franța
Norvegia
Japonia
Olanda
Europa ( ERA-EDTA)
Republic Cehă
Marea Britanie
Turcia
Rusia
I slanda
România
38
Figure 33. Variati on 2011/2006 (%) of the proporti on of diabeti c pati ents incident in RRT (internati onal comparison)
Figure 32. The proporti on of diabeti c pati ents incident in RRT in 2011 (internati onal comparison).
-13.4 %-12.1%-10.1%-8.5%-7.0%-6 .6 %
-2.4 %-1.8%-0.5%
2.3%4 .1%7.0%7.6 %
13.8%14 .3%
21.2%24 .2%24 .8%
37.9 %
NorvegiaAustriaBelgia ( franceză )GreciaSuediaBelgia ( olandeză )OlandaFinlandaEuropa ( EDTA-ERA)FranțaSpaniaRomâniaScoțiaDanemarcaCroațiaBosniaMarea BritanieRusiaI slanda
14 .1
14 .2
15.2
15.8
17.1
20.7
21.0
21.5
21.6
23.0
23.3
23.8
24 .3
24 .6
25.6
29 .2
30.0
30.1
31.5
34 .6
35.0
Olanda
Romania
I slanda
Rusia
Norvegia
Belgia ( franceză )
Belgia ( olandeză )
Europa ( ERA-EDTA)
Franța
Danemarca
Scoția
Suedia
Boznia
Spania
Marea Britanie
Grecia
Croația
Austria
Portugalia
Finlanda
Republica Cehă
-13.4 %
-12.1%
-10.1%
-8.5%
-7.0%
-6 .6 %
-2.4 %
-1.8%
-0.5%
2.3%
4 .1%
7.0%
7.6 %
13.8%
14 .3%
21.2%
24 .2%
24 .8%
37.9 %
Norvegia
Austria
Belgia ( franceză )
Grecia
Suedia
Belgia ( olandeză )
Olanda
Finlanda
Europa ( EDTA-ERA)
Franța
Spania
România
Scoția
Danemarca
Croația
Bosnia
Marea Britanie
Rusia
I slanda
39
Figure 34. The proporti ons (%) of prevalent pati ents treated by hemodialysis (HD), peritoneal dialysis (DP) and renal transplantati on (TR) in Europe and Romania
Prevalent patients
Even though it increased rapidly aft er 2006, the number of prevalent RRT pati ents remained in 2013 one of the lowest in Europe (732 in 2013 compared to the European average of 891 pmi in 2011). Yet the increase rate in Romania conti nues to be one of the highest among the European countries and it is 3 ti mes higher than the European average (see Figure 34, Figure 35).
RRT method
In prevalent patients from Europe, hemodialysis and renal transplantation were used in 2010 in almost similar proportions (51% and 42%) followed by peritoneal dialysis (8%). In Romania, hemodialysis was the most frequently used (74%), followed by renal transplantation (20%) and by peritoneal dialysis (6%) (Figure 35).
In Europe, in incident patients, hemodialysis was the most frequently used method (79%), followed by peritoneal dialysis (15%), while the pre-emptive renal transplantation was performed in 6%. In Romania, HD is also highly dominant, followed by PD and in only 1% of cases by RTx (Figure 36).
Although the increase in patients with a functional kidney graft was seven times higher than the European rate, in Romania the proportion of RTx patients is almost half of the European mean (Figure 40 (see Figure 39).
50.8%
7.6 %
4 1.6 %
74 .3%
6 .1%
19 .6 %
0%
10%
20%
30%
4 0%
50%
6 0%
70%
80%
HD DP TR
Europe ( 2011)
Romania ( 2013)
Figure 35. The proporti ons (%) of incident pati ents treated by hemodialysis (HD), peritoneal dialysis (DP) and renal transplantati on (TR) in Europe and Romania
79 .0%
15.4 %
5.6 %
9 3.3%
5.7%1.0%
0%
25%
50%
75%
100%
HD DP TR
Europe ( EDTA)
Romania
40
19 6
6 24
6 6 5
705
803
84 2
851
86 8
871
874
9 30
9 6 1
9 74
9 80
1, 001
1, 075
1, 09 1
1, 103
1, 184
1, 271
1, 9 24
2, 309
Rusia
România
I slanda
Bosnia
Finlanda
Scoția
Danemarca
Turcia
Marea Britanie
Norvegia
Suedia
Olanda
Republica Cehă
Croația
Austria
Spania
Franța
Grecia
Belgium, olandeză
Belgia, franceză
SU A
Japonia
7.4 %
8.8%
9 .3%
10.2%
10.4 %
11.8%
11.9 %
13.3%
14 .5%
14 .6 %
15.7%
16 .1%
18.1%
18.6 %
20.5%
24 .5%
27.7%
37.3%
4 7.4 %
50.9 %
104 .8%
110.9 %
Scoția
Danemarca
Suedia
Austria
Finlanda
Spania
Grecia
Franța
Croația
Belgium, olandeză
SU A
Norvegia
Japonia
Belgia, franceză
Marea Britanie
Olanda
Bosnia
I slanda
Turcia
Rusia
România
Republica Cehă
Figure 36. Pati ents prevalent on RRT at 31st of December 2011 (pmi) (internati onal comparison) NB. In 2013, in Romania there were 732 pati ents treated pmi
Figure 37. Variati on 2011/2006 (%) in number prevalent pati ents undergoing RRT (internati onal comparison)
41
As compared to the trends in the European countries in 2011/2006, Romania has recorded a higher increase in the percentage of hemodialysis pati ents, a higher decrease in the percentage of peritoneal dialysis pati ents and a signifi cant increase of the prevalent transplanted pati ents (Figure 38).
• Romania has one of the lowest prevalence rates of the pati ents treated by renal replacement therapy methods in Europe, yet one of the fastest increase rates.
• In Romania, hemodialysis is the most frequently used RRT method, while in Europe hemodialysis and renal transplantati on and are used at similar rates.
• Pati ents with functi onal kidney graft have a lower prevalence in Romania, but the rate of increase rate was one of the highest in Europe.
4 24 6
9 5102
126221
33639 039 9
4 344 744 83
500520
538577
6 106 29
0 100 200 300 4 00 500 6 00 700
RusiaBosnia Herțegovina
TurciaSerbia
Romania ( 2012)GreciaCroțiaCehia
DanemarcaMarea Britanie
FinlandaFranța
AustriaSuediaSpaniaOlanda
PortugaliaNorvegia
Patients with a functional kidney graft (per million inhabitants)
3.5%
-20.6 %
23.0%
8.8%
-37.0%138.0%
-50.0% 0.0% 50.0% 100.0% 150.0%
HD
DP
TR
Romania Europe
Figure 38. Variati on 2011/2006 (%) in prevalent RRT pati ents number in Europe and in Romania (HD – hemodialysis; DP – peritoneal dialysis; TR – renal transplantati on)
Figure 39. Trends of the use of renal replacement therapy methods in Europe and in Romania (variance 2011/2006, in percentage)
42
• Romanian dialysis pati ents’ chances of survival are lower in the fi rst 90 days, but bett er aft er 1 and 2 years, as compared to data reported by the EDTA-ERA Registry.
Table XII. Unadjusted survival rate at 90 days, 1 year and 2 years for the cohort 2006-2010, incident dialysis pati ents in Europe and Romania
Parameter 90 days 1 year 2 years
EDTA-ERA RRR EDTA-ERA RRR EDTA-ERA RRR
Age groups (years)• 0-19• 20-44• 45-64• 65-74• 75+
98.8 (97.7-99.4)99.0 (99.8-99.1)96.7 (96.5-96.9)93.4 (93.1-93.7)89.3 (89.0-89.6)
94.1 (90.4-97.8)98.1 (97.5-98.6)93.2 (92.4-93.9)89.6 (88.4-90.7)82.5 (80.3-84.6)
96.0 (94.1-97.3)96.2 (95.8-96.5)89.3 (88.9-89.6)80.6 (80.2-81.0)71.2 (70.8-71.5)
92.7 (88.6-96.8)94.9 (93.9-95.8)86.9 (85.9-87.8)81.8 (80.2-83.3)72.6 (70.0-75.1)
93.8 (91.4-95.6)91.9 (91.4-92.4)81.0 (80.6-81.4)68.0 (67.6-68.3)54.8 (54.5-55.1)
91.2 (86.7-95.7)92.2 (90.8-93.5)80.5 (79.3-81.6)71.7 (69.0-73.0)63.7 (60.9-66.4)
Sex• Male• Female
94.1 (93.3-94.2)93.5 (93.3-93.7)
91.3 (90.5-92.0)92.6 (91.8-93.3)
82.4 (82.1-82.6)81.7 (81.4-82.1)
84.6 (83.6-85.5)86.1 (85.1-87.0)
70.4 (70.1-70.6)70.2 (69.8-70.5)
77.8 (76.8-78.7)79.2 (78.0-80.3)
Primary kidney disease• Diabeti c nephropathy• HBP/Renal vascular disease• Glomerulonephriti s• Other causes/ not specifi ed
95.0 (94.7-95.2)94.2 (93.9-94.5)97.3 (97.0-97.6)92.9 (92.7-93.1)
91.4 (89.8-92.9)92.1 (90.1-94.0)95.8 (94.8-96.7)91.0 (90.2-91.7)
82.9 (82.5-83.3)81.3 (80.8-81.8)91.2 (90.7-91.7)80.8 (80.5-81.1)
82.3 (80.3-84.2)83.0 (80.4-85.5)91.1 (89.7-92.4)84.7 (83.9-85.4)
69.1 (68.6-69.5)67.5 (67.0-68.0)84.1 (83.5-84.7)69.8 (69.5-70.1)
71.4 (69.0-73.7)75.0 (71.8-78.1)86.1 (84.3-87.8)78.4 (77.4-79.3)
Total 93.9 (93.7-94.0) 91.9 (91.3-92.4) 82.1 (82.0-82.3) 85.3 (84.7-85.8) 70.3 (70.1-70.5) 78.4 (77.6-79.1)Red – survival rate lower in EDTA-ERA Registry (EDTA-ERA); Blue – survival rate higher in Romanian Renal Registry (RRR)
Survival on RRT
A cohort of dialysis pati ents who started the therapy in 2006-2010 in Romania (N=10.588) was comparati vely analyzed with corresponding data reported by EDTA-ERA Registry. The unadjusted survival rate of the pati ents treated in Romania is lower within the fi rst three months, but signifi cantly bett er aft er one and two years, which emphasizes once again the defi ciencies in the care before starti ng the dialysis (Table XII, Figure 40).
9 3.9 %82.1%
70.3%
9 1.9 %85.3% 78.4 %
0%
20%
4 0%
6 0%
80%
100%
9 0 days 1 year 2 years
EDTA-ERA
Ro Figure 40. Unadjusted survival rates of incident dialysis pati ents in the period 2006-2010 in Europe (EDTA-ERA) and in Romania (all diff erences are signifi cant)
43
The number of the dialysis centers has not changed. The public sector owns most of the centers (42%).
Public centers treated 11% dialysis pati ents. The most important private provider of dialysis services was Fresenius Nephrocare, followed by Internati onal Helathcare Systems, Diaverum, Avitum (45%, 14%, 11% and 9%) (Table XIII, Figure 41).
All private providers of dialysis have recorded increases in the number of treated pati ents. Diaverum and Avitum had the highest rate of in-crease (Figure 42).
Dialysis providers
Figure 41. The rati o of the dialysis service providers on 31.12.2013 (percentage from the total number
of prevalent pati ents)
Table XIII. Dialysis centers and prevalent pati ents by provider in Romania (2012/2011)
CentersPrevalent dialysis pati ents on 31.12
HD PD Total
2012 2013 2012 2013 2012 2013 2012 2013 Variati on*Public 57 57 1125 1137 136 109 1261 1246 -1.2%Avitum 8 8 827 998 31 44 859 1042 21.3%Diaverum 10 10 868 1178 52 70 920 1248 35.7%Fresenius Nephrocare 35 35 4543 4714 336 281 4879 4995 2.4%Internati onal Healthcare systems 13 13 1108 1192 325 323 1433 1515 5.7%Other 14 14 1080 1103 38 27 1118 1130 1.1%*2013 vs. 2012, in percentage
Public11%
Av itum9%
D iav erum11%
FNC45%
IHS14%
Others10%
-1.2%
21.3%
35.7%
2.4 %5.7%
1.1%
-5%
0%
5%
10%
15%
20%
25%
30%
35%
4 0%
Public Avitum Diaverum FNC IHS Alții
Figure 42. Variati on in prevalent pati ents’ number 2013/2013 (%) by dialysis service provider
44
Figure 43. The proporti on of dialysis pati ents treated in the public sector (%)
Figure 44. The proporti on of PD pati ents by dialysis providers (percentage of the total num-ber of dialysis pati ents)
The percentage of pati ents treated in the public centers conti nued to decrease and reached the lowest level in 2007 (11%) (Figure 42, Figure 43). Since public centers in hospitals functi on as a support for the ambulatory centers, public dialysis stati ons should be maintained, at least in the county hospitals. On the other hand, policies regarding the privati zati on/re-privati zati on of the public stati ons should be discouraged, in order to prevent unfair competi ti on.
There were diff erences in the use of the PD by dialysis providers. In general, PD is preferred only by some of the private providers (Internati onal Healthcare Systems, Fresenius) and by the public sector. In 2013, most of the providers recorded a decrease in prevalent PD pati ents. The increases recorded by Avitum and Diaverum were not enough to stop the decline in PD usage in Romania (Figure 44, Figure 45).
The conti nuous decrease in PD usage noti ced in the public sector (-20%) is alarming, as it regards the area where the renal replacement therapy is chosen and initi ated. One of the causes is that the costs for the initi ati on of peritoneal dialysis are not reimbursed by the NHIH. On the other hand, the policies to promote peritoneal dialysis should be focused not only on hospitals that initi ate renal replacement therapy, but also on programs for predialysis Chronic kidney disease care.
Public18%
Avitum5%
Diaverum6 %
FNC31%
IHS32%
Other8%
9 587
3016 12 12 8
513
7084
88 889 2
2007 2008 2009 2010 2011 2012 2013Public Private
Public18%
Avitum5%
Diaverum6 %
FNC31%
IHS32%
Others8%
45
• Private providers treated 88% of the dialysis pati ents.
• The public sector treated about 12% of the dialysis pati ents. Since public, hospital based sector functi ons as a support for the private ambulatory centers; a further decrease in the proporti on of pati ents treated in the public centers is risky.
-19 .9 %
4 1.9 %34 .6 %
-16 .4 %
-0.6 %
-28.9 % -26 .0%
-4 0%
-30%
-20%
-10%
0%
10%
20%
30%
4 0%
50%
Public Avitum Diaverum FNC I HS Others Romania
Figure 45. The trends in peritoneal dialysis usage by dialysis providers in Romania (PD prevalent pati ents 2012/2006 in percentage)
46
Organization and �inancing
Privatization and the public sector
Aft er the initi ati on of the privati zati on (2004), the dialysis network reorganized. The number of the dialysis centers has doubled, 95 new centers were founded, mostly as ambulatory departments, and the public centers existi ng in hospitals were transformed into dialysis stati ons with a low number of HD units (Figure 46). The private investment in the new centers amounted around 48.000.000 Euro.
Due to the increase in dialysis treatment capacity, more pati ents, which otherwise would have died, could be treated. The number of dialysis pati ents doubled, but the costs per treated pati ent decreased since 2004 unti l 2013 by 19.4% (Figure 47). Accordingly, privati zati on allowed for increasing the economic effi ciency of the dialysis program.
• Privati zati on allowed to treat more pati ents by an increase in the economic effi ciency of the dialysis program.
Most of the dialysis centers originally located in hospitals were converted into public dialysis stati ons with 4-8 machines. These stati ons initi ate RRT and ensure the therapy for dialysis pati ents requiring hospital admission. Unfortunately, the process lead to the disappearance of the dialysis stati ons in some counti es (CL, CV, GR, MH).
Figure 46. Dialysis centers in Romania (2004-2012)
Figure 47. The number of pati ents benefi ti ng from the dialysis program, the program budget (hundreds of thousands of RON) and the costs per pati ent
(Euro, at the reference NBR currency exchange rate for that year)
1 8 0 5 12
2229
113 4
7071
6974
85
106 134137 138
0
30
6 0
9 0
120
150
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
New centers Total
6 , 034 6 , 283 6 , 715 6 , 9 868, 371 8, 4 24 9 , 09 7 9 , 755 10, 4 70 11, 176
3, 508 3, 6 4 4 3, 888 4 , 0284 , 880 4 , 9 51 5, 389 5, 79 6
6 , 819 6 , 871
16,611 16,021 16,44917,263
15,841
13,861 14,071 14,013 14,604 13,910
0
5, 000
10, 000
15, 000
20, 000
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Patients Program buget (thousands RON) Costs per treated patient (EURO)
Costs-19%
Pati ents+100%
47
Figure 49. Modeling the economic impact of the use of PD in 20% of the incident pati ents (Model DP) compared to the current situati on (over 80% hemodialysis – Model HD) and the increase of renal transplantati ons to 30% (Mod-el TR). Five years aft er the introducti on of the PD model, the
esti mated savings compared to the current situati on would allow including all incident pati ents without an increase in the budget.
Figure 48. RRT methods in Romania (2012) and in Europe (EDTA-ERA). Esti mated costs of the replacement therapy for one pati ent/year
(HD – hemodialysis, DP – peritoneal dialysis; TR – renal transplantati on)
The public sector in hospitals is criti cal for running the dialysis program, since private centers functi on as ambulatory centers and dialysis pati ents frequently suff er from comorbiditi es requiring hospital admission. However, the fi nancing of this segment is defi cient: even though hospitals can contract dialysis services, not all County HIH accept to deduct the costs for the initi ati on of the treatment, and the therapy sessions performed for hospitalized dialysis pati ents are not fully reimbursed.
Since the public sector in hospitals is criti cal for the dialysis program, it is necessary to:
• Establish rules for the deducti on of dialysis sessions performed in hospital at the initi ati on of therapy and for admitt ed dialysis pati ents;
• Introduce the health card for the pati ents in the program, which would facilitate treat-ment records.
• Allocate around 5-10% of the program funds for these sessions.
The ratio between RRT methodsCompared to Europe, in Romania the HD is predominant (74% vs. 51%), while RTx is used to a lower rate (20 vs. 41%). Since the costs of therapy diff ers - HD is the most expensive, and RTx is the least - the current combinati on of the methods leads to higher average costs per pati ent under-going renal replacement therapy (Figure 48).
17, 000
12, 500 11, 750
HD D P TR
Chel
tuie
li/an
(Eur
o)
51%74%
8%
7%TR, 42%TR, 20%
Europe ( EDTA) Romania
After 5 years, savings amount 10% per year, allowing new patients to be treated without an increase in the budget for the dialysis program
Spen
ding
s pe
year
(mill
ion
RON
)
48
Moreover, from both a medical and an economical perspecti ve, it would be ideal to combine PD with RTx, and to initi ate HD only in those pati ents who have no indicati ons for or refuse PD or RTx, and in those in which these methods have failed.
A model of the economic impact of the increase to 20% in the rati o of incident peritoneal dialysis pati ents and to 400 kidney graft s per year shows that aft er 5 years the obtained savings would allow newly-included pati ents to be treated without increasing the dialysis program budget (Figure 49).
To improve pati ents’ allocati on to RRT methods, the following are needed:• Programs addressing pre-dialysis CKD pati ents care;• Financing at least 400 graft s per year (eventually, unlimited number of graft s);• Conditi oning the reimbursement of medicine costs in the post-renal transplantati on
program by reporti ng to the Romanian Renal Registry, similar to the dialysis program.• Increasing tariff s for peritoneal dialysis.
Treatment quality
There is no system to assess the therapy performances, although such a system was one of the prerequisites for the initi ati on of the privati zati on, and most of the private providers have implemented quality management systems.
Moreover, a diff erenti ated payment of services based on the quality assessment can in perspecti ve be introduced .
Collecti ng data on medical performance by Romanian Renal Registry would allow obtaining informati on on the quality assessment and requires:• to establish compulsory reporti ng of quality of
therapy parameters by the providers;• to properly reorganize and fi nance the Romanian
Renal Registry.
49
Prices of the dialysis services
The dialysis therapy is contracted as a package of services per a hemodialysis session, respecti vely per 1 year of therapy for peritoneal dialysis. The package includes the necessary consumables (dialysis soluti ons, bloodlines, fi stula needles dialyzer, etc.), medicines (heparin, epoeti ns, iron, phosphate chelati ng agents, vitamin D analogues, cinacalcet), lab tests, pati ent transportati on, food, dietary and psychological counseling. It is the most complete package in the EU and despite that, the price is the lowest.
Within the last 4 years, a series of infl uences signifi cantly increased the costs of dialysis: the increase of the VAT by 4%, the increase of the price of medicines and introducti on of new medicines (cinacalcet, paricalcitol), 10% for hemodialysis and 15% for peritoneal dialysis (new soluti ons for peritoneal dialysis) and the increase of the Leu/EURO exchange rate (11%).
The details on the expenses of private providers cannot be obtained, due to their confi denti al nature. That is why the impact analysis can only be performed by a weighted calculati on. The weighted calculati on of the impact indicates increases of the expenses by 13% for hemodialysis and 24% for peritoneal dialysis. The impact on peritoneal dialysis is higher due to the newly introduced soluti ons, which are more expensive (Table XIV).
The increase of Leu/EURO exchange rate, the increase of VAT, of cost of medicines (including the introducti on of new preparati ons) and of the wages increased the costs of dialysis therapy. Since the increase of expenses directly refl ects on the quality of therapy, it is necessary to increase prices by 10-13% for HD and by 15-20% for PD.
Table XIV. Weighted infl uences on the expenses of the Pro-gram for dialysis renal replacementa) Haemodialysis
Nature of cost Weight within the expenses (%)
Increase (%) Weighted increase (%)
HD materials 26.2% 18.35 4.8%Medicines 20.6% 23.8% 4.9%Other materials 2.1% 5.0% 0.1%Laboratory tests 2.0% 0.0% 0.0%Other medical costs 2.1% 0.0% 0.0%Other costs 10.8% 5.0% 0.5%Transportati on 10.4% 5.0% 0.5%Wage costs 25.7% 9.0% 2.3%Total 100.0% - 13.2%
b) Peritoneal dialysis
Nature of cost Weight within the expenses (%)
Increase (%) Weighted increase (%)
PD materials 3.4 18.1% 0.6%Dialysis soluti ons 62.8 29.4% 18.5%Medicines 13.4 23.8% 3.2%Laboratory tests 1.9 0.0% 0.0%Other medical issues 0.8 0.0% 0.0%Other costs 2.1 5.0% 0.1%Soluti ons transportati on 7.4 5.0% 0.4%Pati ent transportati on - 0.7% 0.7%Wage costs 8.1 9.0% 0.7%Total 100.0 - 24.2%
50
Conclusions
1. Chronic kidney disease has a higher prevalence in Romania that in the USA: 13.1% vs. 11.5%; the esti mated number of adult persons with CKD in Romania is about 1,900,000.
2. Since the number of CKD pati ents with medium-high risk is 565,000, a nephrologist should care approximately 1,900 pati ents.
3. CKD pati ents suff er more oft en from diabetes mellitus, HBP, strokes and heart failure, and their death risk is twice higher. Consequently, CKD care should be multi disciplinary (diabetology, cardiology and nephrology).
4. The medical assistance is mainly provided in hospital (over a quarter of the pati ents are admitt ed into hospital), regardless of the state of the kidney, and the CKD pati ents have almost twice as many visits in the ambulatory clinic. Thus, it is necessary to organize multi disciplinary CKD medical care programs that must promote ambulatory care.
5. The framework contract for 2014 included sti pulati ons in favor of the multi disciplinary care of CKD pati ents in the ambulatory clinic, but the Applicati on norms are relati vely less precise and cannot be implemented, since the 10th version of the Internati onal Classifi cati on of Diseases used in Romania is not updated to include Chronic kidney disease (N18). Temporarily, unti l it is brought up-to-date, we suggest accepti ng the N18 code (in the current classifi cati on - Chronic kidney failure) for the Chronic kidney disease in hospital admitt ance cases and the code 685 in the ambulatory pati ents.
6. The number of the RRT pati ents in Romania (732 pmi) is below the European average of the year 2012 (947 pmi), but it has a rate of increase above the European mean.
7. The annual rate of increase in RRT pati ents’ number is 7-8% and shall only decrease in 2016-2017, when most of the existi ng pati ents shall be able to receive treatment, and the death rates would equal the rate of the therapy inclusion. That is why:
a. The rate of increase in HD pati ents number esti mated for 2014-2015 is 6-7%.
b. In 2014, 11,600 pati ents shall be treated by dialysis, and in 2015, 12,200.
c. In 2014 there will be 3,100 newly included pati ents, and in 2015, 3,400.
8. The use of peritoneal dialysis is decreasing and should the current trends maintain, it will disappear by 2017. In order to change this decreasing trend, the following could be useful:
a. Programs addressing the CKD pati ents before dialysis initi ati on;
b. Programs addressing the physicians in hospitals and in the specialty ambulatory departments;
c. Adjusti ng the prices for peritoneal dialysis.
9. Renal transplantati on:
a. The number of graft s increased and the graft s from deceased donors were predominant in the incident transplant pati ents, but only 8% of incident pati ents undergone non-preempti ve transplantati on;
b. At least 300-400 graft s would be necessary each year in order to allow transplantati on to contribute eff ecti vely to RRT in Romania. On principle, the number of graft s for which the costs are deducted should not be limited, as wasti ng the available graft s from fi nancial reasons is meaningless;
c. The post-transplantati on program shall include 2989 and respecti vely 3255 pati ents for the years 2014 and 2015.
d. In order to have a proper evidence of RTx pati ents, compulsory reporti ng of the transplant pati ents to the Romanian Renal Registry
51
should be introduced, by conditi oning the deducti on of 100% deducted prescripti on for the pati ents in the post-transplantati on program by reporti ng.
10. Hemodiafi ltrati on and automated peritoneal dialysis treatments are less frequently used. In order to use them more effi ciently it is indicated to change the currently accepted by NHIH prescripti on criteria.
11. The renal replacement therapy is inhomogeneously provided at the territorial level:
a. The center of Transilvania, South of Muntenia and Moldavia (especially in the counti es IL, CL, GR, OT, MS, CV) conti nue to have a lower coverage with dialysis faciliti es and low perspecti ves for improvement.
b. The indicati ons of the use of renal replacement therapy methods signifi cantly vary from one area to another: in the center of Transilvania, hemodialysis and renal transplantati on are especially used and peritoneal dialysis does not exist, while in the South of Moldavia and the East of Muntenia, hemodialysis and peritoneal dialysis are mainly used and renal transplantati on is rare.
12. The characteristi cs of the incident RRT Romanian pati ents are changing and are converging to European incident pati ents’ characteristi cs: the age and the proporti ons of pati ents with diabetes mellitus and cardio-vascular comorbiditi es are increasing.
13. Nephrology care before initi ati ng dialysis seems to be defi cient: the proporti on of pati ents without a known diagnosis of the primary kidney dis-ease tends to decrease, but is sti ll too high, which emphasizes the need for programs addressing predialysis CKD pati ents.
14. There is no system for assessment of medical performance of the dialysis centers. Collecti ng data on the medical performance at Romanian Renal Registry would allow to obtain informati on for the quality assessment and requires:
a. to establish compulsory reporti ng of the quality of therapy parameters by the dialysis providers;
b. to properly reorganize and fi nance the Romanian Renal Registry, by in-troducing a fee of 0.5% of the value of the contracts for dialysis services.
15. The public sector in hospitals provides 11% of the dialysis services and its existence is criti cal for the dialysis program. That is why it is necessary to:
a. redefi ne rules for the deducti on of dialysis sessions performed in hospital at the initi ati on of therapy and for admitt ed dialysis pati ents;
b. introduce the health card for the pati ents in the program to facilitate proper treatment records;
c. allocate around 5-10% of the program funds for these sessions.
16. Privati zati on allowed treati ng more pati ents by increasing the economic effi ciency of the dialysis program. Practi cally, the costs per treated pati ent decreased by 19% since 2004 unti l 2013. Unfortunately, the acquired experience was not extended to other health programs.
17. The increase of the Leu/EURO exchange rate, the increase of the VAT, of the cost of medicines (including the new medicines and peritoneal dialysis soluti ons) and of the wages increased the costs of dialysis therapy. Since the increase of expenses directly refl ects on the quality of therapy, it is necessary to increase prices by 10-13% for hemodialysis and by 15-20% for peritoneal dialysis.
52
Appendix 1. The method for the calculati on of the standardized mortality rati o
Nati onal reference mortality rates were calculated on a cohort of 11,829 hemodialysis pati ents alive on January 1st 2010, monitored over a 3-year period. Pati ents who started hemodialysis 90 days before January 1st were excluded, and those who received renal transplantati on or were no longer included in the records in the observati on period were censored.
As the major determinants of mortality are age and primary kidney disease (especially diabeti c nephropathy), the nati onal mortality rates were calculated by 8 age groups and 4 eti ologies, including diabetes mellitus, in relati on to the frequency of the primary kidney diseases reported in Romania)9.
By using these nati onal rates, the expected number of deaths in a certain populati on can be calculated. The standardized mortality rati o is the rati o between the expected number of deaths noti ced in the respecti ve populati on and the expected rati o. The European Renal Registry uses the same procedure for comparisons.
The assessment of the survival rate by SMR is superior to the assessment of the crude mortality rate. However, the reference value is the nati onal average mortality rate, which does not necessarily correspond to an opti mum care. On the other hand, due to the diversity and the multi ple comorbiditi es of the hemodialysis pati ents, the SMR must also be interpreted with care, as an orienti ng comparison. Thus, a center can provide an excellent care to a subgroup of pati ents and a defi cient care to another subgroup, which would lead to a SMR of almost 1.00 by cancelling the two eff ects.
Accordingly, SMR is only an orienti ng parameter, which can indicate a care issue when the value is below 1, without allowing the identi fi cati on of causes and imposing additi onal analyses.
Appendices
53
Appendix 2. The method of calculati on of the survival rates
The data regarding the evoluti on of HD and PD pati ents were obtained from the Romanian Renal Registry, and those related to the survival of (preempti ve and non-preempti ve) RT pati ents were obtained from the “Fundeni” Clinical Insti tute.
The data included 9,540 adult incident pati ents undergoing renal replacement therapy (HD, PD and RT) in the period 2008-2011 (4 years), with a total monitoring period of 5 years: 01.01.2008-31.12.2012. The analysis used the renal replacement therapy method on day 91. The pati ents lost to follow-up were censored. The characteristi cs of the investi gated pati ents are presented in Table XV.
Table XV. The characteristi cs of the pati ents investi gated for the survival analysis
Total TR HD PD p
Number of pati ents 9540 490 8050 1000
Male (%) 57 64 58 51 <0,001Primary kidney disease (%)• Glomerulonephriti s• Tubule-intersti ti al nephriti s• Hereditary nephropathies• Diabeti c nephropathy• Renal vascular diseases• Unknown/ Others
1712
614
744
429671
35
1612
614
714
1613
5171237
<0.001
Death causes (%)• Cardio-vascular• Neoplasia• Infecti ous• Gastrointesti nal• Other causes/ unknown
48332
44
174134
-8
48332
44
47221
48
<0.001
The unadjusted survival rates were calculated (Kaplan Meier), which were subsequently adjusted in a Cox logisti c regression model.
54
Appendix 3. Dialysis centers, machines and pati ents treated on a machine in the counti es of Romania in 2012, 2013 and variance 2013/2012 (in percentage)
County Populati on HD pati ents Dialysis centers HD machines
2012 2013 Variance 2012 2013 Variance 2012 2013 Variance
Ap
Variance machine
No pmi No pmi No pmi No pmi No pmi Pati ents/machine
No pmi Pati ents/machine
AB 342,376 168 491 192 561 14.3% 1 2.9 2 5.8 100.0% 39 114 4.3 40 116.8 4.8 2.6% 11.4%
AG 612,431 283 462 312 509 10.2% 3 4.9 3 4.9 0.0% 59 96 4.8 73 119.2 4.3 23.7% -10.9%
AR 430,629 179 416 187 434 4.5% 2 4.6 2 4.6 0.0% 30 70 6.0 35 81.3 5.3 16.7% -10.5%
B + IF 2,272,163 1,348 593 1,546 680 14.7% 21 9.2 20 8.8 -4.8% 329 145 4.1 393 173.0 3.9 19.5% -4.0%
BC 616,168 326 529 318 516 -2.5% 4 6.5 5 8.1 25.0% 63 102 5.2 70 113.6 4.5 11.1% -12.2%
BH 575,398 351 610 351 610 0.0% 3 5.2 2 3.5 -33.3% 49 85 7.2 73 126.9 4.8 49.0% -32.9%
BN 286,225 109 381 126 440 15.6% 2 7.0 2 7.0 0.0% 32 112 3.4 33 115.3 3.8 3.1% 12.1%
BR 321,212 199 620 199 620 0.0% 3 9.3 3 9.3 0.0% 56 174 3.6 67 208.6 3.0 19.6% -16.4%
BT 412,626 219 531 227 550 3.7% 3 7.3 2 4.8 -33.3% 31 75 7.1 47 113.9 4.8 51.6% -31.6%
BV 549,217 252 459 288 524 14.3% 5 9.1 5 9.1 0.0% 57 104 4.4 85 154.8 3.4 49.1% -23.4%
BZ 451,069 139 308 156 346 12.2% 1 2.2 1 2.2 0.0% 31 69 4.5 31 68.7 5.0 0.0% 12.2%
CJ 691,106 435 629 454 657 4.4% 7 10.1 7 10.1 0.0% 122 177 3.6 119 172.2 3.8 -2.5% 7.0%
CL 306,691 76 248 84 274 10.5% 1 3.3 1 3.3 0.0% 21 68 3.6 21 68.5 4.0 0.0% 10.5%
CS 295,579 91 308 88 298 -3.3% 2 6.8 2 6.8 0.0% 29 98 3.1 32 108.3 2.8 10.3% -12.4%
CT 684,082 304 444 330 482 8.6% 5 7.3 5 7.3 0.0% 76 111 4.0 86 125.7 3.8 13.2% -4.1%
CV 210,177 43 205 90 428 109.3% 1 4.8 2 9.5 100.0% 17 81 2.5 18 85.6 5.0 5.9% 97.7%
DB 518,745 182 351 222 428 22.0% 3 5.8 3 5.8 0.0% 55 106 3.3 58 111.8 3.8 5.5% 15.7%
DJ 660,544 336 509 350 530 4.2% 3 4.5 3 4.5 0.0% 68 103 4.9 73 110.5 4.8 7.4% -3.0%
GJ 341,594 196 574 208 609 6.1% 3 8.8 3 8.8 0.0% 58 170 3.4 68 199.1 3.1 17.2% -9.5%
GL 536,167 114 213 124 231 8.8% 3 5.6 3 5.6 0.0% 38 71 3.0 39 72.7 3.2 2.6% 6.0%
GR 281,422 71 252 74 263 4.2% 1 3.6 1 3.6 0.0% 12 43 5.9 22 78.2 3.4 83.3% -43.1%
HD 418,565 251 600 253 604 0.8% 4 9.6 4 9.6 0.0% 75 179 3.3 62 148.1 4.1 -17.3% 21.9%
HR 310,867 144 463 150 483 4.2% 4 12.9 4 12.9 0.0% 40 129 3.6 40 128.7 3.8 0.0% 4.2%
IL 274,148 90 328 101 368 12.2% 2 7.3 2 7.3 0.0% 29 106 3.1 28 102.1 3.6 -3.4% 16.2%
IS 772,348 446 577 499 646 11.9% 4 5.2 4 5.2 0.0% 102 132 4.4 102 132.1 4.9 0.0% 11.9%
MH 265,390 180 678 184 693 2.2% 2 7.5 2 7.5 0.0% 41 154 4.4 42 158.3 4.4 2.4% -0.2%
MM 478,659 206 430 224 468 8.7% 3 6.3 3 6.3 0.0% 67 140 3.1 61 127.4 3.7 -9.0% 19.4%
MS 550,846 183 332 196 356 7.1% 3 5.4 3 5.4 0.0% 56 102 3.3 56 101.7 3.5 0.0% 7.1%
NT 470,766 262 557 268 569 2.3% 4 8.5 4 8.5 0.0% 62 132 4.2 63 133.8 4.3 1.6% 0.7%
55
County Populati on HD pati ents Dialysis centers HD machines
2012 2013 Variance 2012 2013 Variance 2012 2013 Variance
Ap
Variance machine
No pmi No pmi No pmi No pmi No pmi Pati ents/machine
No pmi Pati ents/machine
OT 436,400 146 335 163 374 11.6% 2 4.6 2 4.6 0.0% 27 62 5.4 35 80.2 4.7 29.6% -13.9%
PH 762,886 320 419 339 444 5.9% 3 3.9 4 5.2 33.3% 61 80 5.2 88 115.4 3.9 44.3% -26.6%
SB 397,322 253 637 264 664 4.3% 4 10.1 4 10.1 0.0% 89 224 2.8 80 201.3 3.3 -10.1% 16.1%
SJ 224,384 88 392 99 441 12.5% 2 8.9 2 8.9 0.0% 19 85 4.6 19 84.7 5.2 0.0% 12.5%
SM 344,360 132 383 134 389 1.5% 2 5.8 2 5.8 0.0% 30 87 4.4 31 90.0 4.3 3.3% -1.8%
SV 634,810 332 523 339 534 2.1% 4 6.3 4 6.3 0.0% 84 132 4.0 77 121.3 4.4 -8.3% 11.4%
TL 213,083 113 530 116 544 2.7% 2 9.4 2 9.4 0.0% 35 164 3.2 44 206.5 2.6 25.7% -18.3%
TM 683,540 314 459 308 451 -1.9% 5 7.3 5 7.3 0.0% 94 138 3.3 73 106.8 4.2 -22.3% 26.3%
TR 380,123 147 387 159 418 8.2% 2 5.3 2 5.3 0.0% 33 87 4.5 33 86.8 4.8 0.0% 8.2%
VL 371,714 177 476 204 549 15.3% 3 8.1 3 8.1 0.0% 36 97 4.9 52 139.9 3.9 44.4% -20.2%
VN 340,310 156 458 172 505 10.3% 2 5.9 2 5.9 0.0% 35 103 4.5 37 108.7 4.6 5.7% 4.3%
VS 395,499 190 480 224 566 17.9% 3 7.6 3 7.6 0.0% 59 149 3.2 59 149.2 3.8 0.0% 17.9%
Romania 20,121,641 9,551 475 10,322 513 8.1% 137 6.8 138 6.9 0.7% 2346 117 4.1 2565 127.5 4.0 9.3% -1.2%
56
Appendix 4. Dialysis pati ents registered on 31.12.2012 and 31.12.2013 in the counti es of Romania and the variance 2013/2012 (in percentage)
County Populati on HD pati ents PD pati ents Total
2012 2013 Variance 2012 2013 Variance 2012 2013 Variance
No pmi No pmi No pmi No pmi No pmi No pmi
AB 342,376 168 491 192 561 14.3% 3 8.8 3 8.8 0.0% 171 499 195 569.5 14.0%
AG 612,431 283 462 312 509 10.2% 14 22.9 11 18.0 -21.4% 297 485 323 527.4 8.8%
AR 430,629 179 416 187 434 4.5% 7 16.3 3 7.0 -57.1% 186 432 190 441.2 2.2%
B + IF 2,272,163 1,348 593 1,546 680 14.7% 166 73.1 157 69.1 -5.4% 1514 666 1703 749.5 12.5%
BC 616,168 326 529 318 516 -2.5% 29 47.1 26 42.2 -10.3% 355 576 344 558.3 -3.1%
BH 575,398 351 610 351 610 0.0% 11 19.1 21 36.5 90.9% 362 629 372 646.5 2.8%
BN 286,225 109 381 126 440 15.6% 0 0.0 0 0.0 0.0% 109 381 126 440.2 15.6%
BR 321,212 199 620 199 620 0.0% 32 99.6 30 93.4 -6.3% 231 719 229 712.9 -0.9%
BT 412,626 219 531 227 550 3.7% 14 33.9 13 31.5 -7.1% 233 565 240 581.6 3.0%
BV 549,217 252 459 288 524 14.3% 40 72.8 27 49.2 -32.5% 292 532 315 573.5 7.9%
BZ 451,069 139 308 156 346 12.2% 70 155.2 72 159.6 2.9% 209 463 228 505.5 9.1%
CJ 691,106 435 629 454 657 4.4% 10 14.5 11 15.9 10.0% 445 644 465 672.8 4.5%
CL 306,691 76 248 84 274 10.5% 0 0.0 0 0.0 0.0% 76 248 84 273.9 10.5%
CS 295,579 91 308 88 298 -3.3% 19 64.3 19 64.3 0.0% 110 372 107 362.0 -2.7%
CT 684,082 304 444 330 482 8.6% 30 43.9 21 30.7 -30.0% 334 488 351 513.1 5.1%
CV 210,177 43 205 90 428 109.3% 1 4.8 1 4.8 0.0% 44 209 91 433.0 106.8%
DB 518,745 182 351 222 428 22.0% 18 34.7 17 32.8 -5.6% 200 386 239 460.7 19.5%
DJ 660,544 336 509 350 530 4.2% 32 48.4 28 42.4 -12.5% 368 557 378 572.3 2.7%
GJ 341,594 196 574 208 609 6.1% 13 38.1 13 38.1 0.0% 209 612 221 647.0 5.7%
GL 536,167 114 213 124 231 8.8% 56 104.4 54 107.6 -3.6% 170 317 178 332.0 4.7%
GR 281,422 71 252 74 263 4.2% 0 0.0 0 0.0 0.0% 71 252 74 263.0 4.2%
HD 418,565 251 600 253 604 0.8% 4 9.6 6 14.3 50.0% 255 609 259 618.8 1.6%
HR 310,867 144 463 150 483 4.2% 1 3.2 1 3.2 0.0% 145 466 151 485.7 4.1%
IL 274,148 90 328 101 368 12.2% 8 29.2 6 21.9 -25.0% 98 357 107 390.3 9.2%
IS 772,348 446 577 499 646 11.9% 93 120.4 71 91.9 -23.7% 539 698 570 738.0 5.8%
MH 265,390 180 678 184 693 2.2% 12 45.2 15 56.5 25.0% 192 723 199 749.8 3.6%
MM 478,659 206 430 224 468 8.7% 8 16.7 6 12.5 -25.0% 214 447 230 480.5 7.5%
57
County Populati on HD pati ents PD pati ents Total
2012 2013 Variance 2012 2013 Variance 2012 2013 Variance
No pmi No pmi No pmi No pmi No pmi No pmi
MS 550,846 183 332 196 356 7.1% 7 12.7 9 16.3 28.6% 190 345 205 372.2 7.9%
NT 470,766 262 557 268 569 2.3% 17 36.1 10 21.2 -41.2% 279 593 278 590.5 -0.4%
OT 436,400 146 335 163 374 11.6% 18 41.2 13 29.8 -27.8% 164 376 176 403.3 7.3%
PH 762,886 320 419 339 444 5.9% 17 22.3 16 21.0 -5.9% 337 442 355 465.3 5.3%
SB 397,322 253 637 264 664 4.3% 23 57.9 22 55.4 -4.3% 276 695 286 719.8 3.6%
SJ 224,384 88 392 99 441 12.5% 0 0.0 0 0.0 0.0% 88 392 99 441.2 12.5%
SM 344,360 132 383 134 389 1.5% 29 84.2 27 78.4 -6.9% 161 468 161 467.5 0.0%
SV 634,810 332 523 339 534 2.1% 8 12.6 10 15.8 25.0% 340 536 349 549.8 2.6%
TL 213,083 113 530 116 544 2.7% 1 4.7 1 4.7 0.0% 114 535 117 549.1 2.6%
TM 683,540 314 459 308 451 -1.9% 16 23.4 27 39.5 68.8% 330 483 335 490.1 1.5%
TR 380,123 147 387 159 418 8.2% 11 28.9 4 10.5 -63.6% 158 416 163 428.8 3.2%
VL 371,714 177 476 204 549 15.3% 11 29.6 11 29.6 0.0% 188 506 215 578.4 14.4%
VN 340,310 156 458 172 505 10.3% 55 161.6 57 167.5 3.6% 211 620 229 672.9 8.5%
VS 395,499 190 480 224 566 17.9% 15 37.9 15 37.9 0.0% 205 518 239 604.3 16.6%
Romania 20,121,641 9,551 475 10,322 513 8.1% 919 45.7 854 42.4 -7.1% 10,470 520 11,176 555.4 6.7%
58
Appendix 5. Pati ents incident in hemodialysis (HD), peritoneal dialysis (PD), non-preempti ve renal transplantati on (TR) and the number of deaths in 2013 in the counti es of Romania
County Populati on HD + PD pati ents Newly included pati ents 2013 Deaths 2013
prevalent pati ents**
HD PD PD/HD HD+DP TR No % pmi
Average pmi No No % No % pmi No % pmi
AB 342,376 183 535.7 34 0 0.0 34 18.5 99.3 1 0.5 2.9 18 9.8 52.6
AG 612,431 316 515.3 27 1 3.7 28 8.9 45.7 1 0.3 1.6 45 14.3 73.5
AR 430,629 192 445.1 74 0 0.0 74 38.6 171.8 2 1.0 4.6 49 25.6 113.8
B + IF 2,272,163 1,647 724.7 580 44 7.6 624 37.9 274.6 125 7.6 55.0 224 13.6 98.6
BC 616,168 350 568.0 37 11 29.7 48 13.7 77.9 6 1.7 9.7 52 14.9 84.4
BH 575,398 381 661.4 105 5 4.8 110 28.9 191.2 8 2.1 13.9 84 22.1 146.0
BN 286,225 119 416.9 35 0 0.0 35 29.3 122.3 3 2.5 10.5 23 19.3 80.4
BR 321,212 235 731.3 54 9 16.7 63 26.8 196.1 0 0.0 0.0 26 11.1 80.9
BT 412,626 238 577.8 28 1 3.6 29 12.2 70.3 4 1.7 9.7 24 10.1 58.2
BV 549,217 312 568.4 82 3 3.7 85 27.2 154.8 6 1.9 10.9 37 11.9 67.4
BZ 451,069 222 492.7 34 10 29.4 44 19.8 97.5 0 0.0 0.0 29 13.0 64.3
CJ 691,106 459 663.7 84 2 2.4 86 18.8 124.4 5 1.1 7.2 50 10.9 72.3
CL 306,691 79 257.3 6 0 0.0 6 7.6 19.6 0 0.0 0.0 2 2.5 6.5
CS 295,579 110 372.7 6 4 66.7 10 9.1 33.8 2 1.8 6.8 27 24.5 91.3
CT 684,082 350 511.9 92 2 2.2 94 26.8 137.4 2 0.6 2.9 57 16.3 83.3
CV 210,177 65 306.9 15 1 6.7 16 24.8 76.1 1 1.6 4.8 10 15.5 47.6
DB 518,745 217 417.8 61 1 1.6 62 28.6 119.5 1 0.5 1.9 9 4.2 17.3
DJ 660,544 380 574.7 103 5 4.9 108 28.5 163.5 1 0.3 1.5 42 11.1 63.6
GJ 341,594 218 639.2 31 3 9.7 34 15.6 99.5 3 1.4 8.8 28 12.8 82.0
GL 536,167 176 329.0 20 12 60.0 32 18.1 59.7 2 1.1 3.7 27 15.3 50.4
GR 281,422 71 253.2 0 0 - 0 0.0 0.0 0 0.0 0.0 12 16.8 42.6
HD 418,565 256 610.4 88 3 3.4 91 35.6 217.4 4 1.6 9.6 34 13.3 81.2
HR 310,867 149 479.8 22 0 0.0 22 14.7 70.8 3 2.0 9.7 9 6.0 29.0
IL 274,148 102 372.1 18 0 0.0 18 17.6 65.7 0 0.0 0.0 7 6.9 25.5
IS 772,348 561 726.6 274 7 2.6 281 50.1 363.8 9 1.6 11.7 66 11.8 85.5
MH 265,390 197 742.0 36 1 2.8 37 18.8 139.4 3 1.5 11.3 31 15.7 116.8
MM 478,659 224 468.5 44 0 0.0 44 19.6 91.9 0 0.0 0.0 18 8.0 37.6
MS 550,846 199 361.9 18 0 0.0 18 9.0 32.7 3 1.5 5.4 14 7.0 25.4
59
County Populati on HD + PD pati ents Newly included pati ents 2013 Deaths 2013
prevalent pati ents**
HD PD PD/HD HD+DP TR No % pmi
Average pmi No No % No % pmi No % pmi
NT 470,766 287 608.9 24 0 0.0 24 8.4 51.0 3 1.0 6.4 52 18.1 110.5
OT 436,400 171 391.7 30 3 10.0 33 19.3 75.6 0 0.0 0.0 28 16.4 64.2
PH 762,886 346 453.3 67 5 7.5 72 20.8 94.4 0 0.0 0.0 62 17.9 81.3
SB 397,322 285 717.5 67 3 4.5 70 24.6 176.2 6 2.1 15.1 38 13.3 95.6
SJ 224,384 91 407.0 28 0 0.0 28 30.7 124.8 1 1.1 4.5 18 19.7 80.2
SM 344,360 163 473.3 27 3 11.1 30 18.4 87.1 9 5.5 26.1 19 11.7 55.2
SV 634,810 350 550.8 133 0 0.0 133 38.0 209.5 0 0.0 0.0 56 16.0 88.2
TL 213,083 114 533.4 21 0 0.0 21 18.5 98.6 1 0.9 4.7 6 5.3 28.2
TM 683,540 334 489.2 65 5 7.7 70 20.9 102.4 9 2.7 13.2 50 15.0 73.1
TR 380,123 161 422.2 48 3 6.3 51 31.8 134.2 0 0.0 0.0 31 19.3 81.6
VL 371,714 209 562.3 44 5 11.4 49 23.4 131.8 2 1.0 5.4 26 12.4 69.9
VN 340,310 222 652.6 45 3 6.7 48 21.6 141.0 0 0.0 0.0 14 6.3 41.1
VS 395,499 226 572.1 37 0 0.0 37 16.4 93.6 1 0.4 2.5 33 14.6 83.4
Romania 20,121,641 10,966 545.0 2,644 155 5.9 2,799 25.5 139.1 227 2.1 11.3 1,487 13.6 73.9
*12 month average for the year 2012
60
Dialysis Center County Prevalent pati ents1
HD PD HD + PD
2012 2013 Variance 2012 2013 Variance 2012 2013 Variance2
1. Nefromed Dialysis Centers Alba-Iulia AB 168 186 10.7% 3 3 0.0% 171 189 10.5%
2. Alba-Iulia County Emergency Hospital AB 0 6 - 0 0 - 0 6 -
3. FNC Pitesti AG 167 179 7.2% 11 11 0.0% 178 190 6.7%
4. Nefrocare CL - Câmpulung AG 46 55 19.6% 0 0 - 46 55 19.6%
5. Arges Pitesti County Hospital AG 70 78 11.4% 3 0 -100.0% 73 78 6.8%
6. Hemo-Vest – Arad AR 149 157 5.4% 6 3 -50.0% 155 160 3.2%7. Arad County Clinical Emergency Hospital AR 30 30 0.0% 1 0 -100.0% 31 30 -3.2%
8. IHS "Sf. Ioan" Bucharest B 154 137 -11.0% 42 32 -23.8% 196 169 -13.8%
9. CMDTAMP Bucharest B 36 39 8.3% 0 0 - 36 39 8.3%
10. FNC "Dr. Carol Davila" Bucharest B 348 344 -1.1% 16 17 6.3% 364 361 -0.8%
11. Fundeni Clinical Insti tute - Pediatric Dialysis B 5 9 80.0% 8 5 -37.5% 13 14 7.7%
12. Fundeni Clinical Insti tute - Renal transplantati on B 8 8 0.0% 0 0 - 8 8 0.0%13. "N. Paulescu” Insti tute for Nutriti on and Metabolic
Diseases B 22 38 72.7% 10 9 -10.0% 32 47 46.9%
14. IHS - "Sf. Pantelimon" Bucharest B 118 136 15.3% 2 6 200.0% 120 140 16.7%
15. IHS Fundeni B 91 92 1.1% 43 43 0.0% 134 135 0.7%
16. Diaverum Bucharest – Industriilor B 134 136 1.5% 18 12 -33.3% 152 148 -2.6%
17. Diaverum Bucuresti - Splai Independentei B 139 157 12.9% 4 4 0.0% 143 161 12.6%
18. DIA MEDICAL PORT - Bucharest B 50 101 102.0% 0 0 - 50 101 102.0%
19. Gral Medical Bucharest B 72 92 27.8% 0 0 - 72 88 22.2%
20. Nefro Care Center Bucuresti B 72 98 36.1% 4 2 -50.0% 76 99 30.3%21. “Dr Carol Davila” Clinical Nephrology Hospital - Bu-
charest B 19 37 94.7% 12 11 -8.3% 31 47 51.6%
22. "Sf. Ioan" Clinical Emergency Hospital Bucharest B 28 21 -25.0% 0 0 - 28 21 -25.0%23. "Grigore Alexandrescu" Children Clinical Emergency
Hospital B 0 0 - 0 0 - 0 0 -
24. Floreasca Clinical Emergency Hospital Bucharest B 15 11 -26.7% 2 2 0.0% 17 13 -23.5%
25. Fundeni Clinical Hospital - Nephrology B 5 25 400.0% 3 13 333.3% 8 38 375.0%
26. "Marie Curie" Children Emergency Hospital Bucharest B 0 14 - 0 0 - 0 13 -
Appendix 6. Prevalent pati ents in the dialysis centers in Romania on 31.12.2011 vs. 31.12.2010 and the variance 2012/2011 in percentage (in the alphabeti cal order of the counti es)
61
Dialysis Center County Prevalent pati ents1
HD PD HD + PD
2012 2013 Variance 2012 2013 Variance 2012 2013 Variance2
27. University Emergency Hospital Bucharest B 32 51 59.4% 2 1 -50.0% 34 52 52.9%
28. FNC Bacau BC 200 205 2.5% 29 26 -10.3% 229 231 0.9%
29. MALP Moinesti - Dialysis stati on BC 0 36 - 0 0 - 0 36 -
30. Renal Med Bacau Onesti BC 61 60 -1.6% 0 0 - 61 60 -1.6%
31. Bacau County Emergency Hospital BC 26 17 -34.6% 0 0 - 26 17 -34.6%32. Moinesti Dialysis stati on BC 39 0 -100.0% 0 0 - 39 0 -100.0%
33. FNC Oradea BH 194 194 0.0% 0 0 - 194 194 0.0%
34. Renamed Nefrodial – Oradea BH 157 157 0.0% 11 21 90.9% 168 178 6.0%
35. Diaverum Bistrita BN 85 97 14.1% 0 0 - 85 97 14.1%
36. Bistrita Nasaud County Emergency Hospital BN 24 29 20.8% 0 0 - 24 29 20.8%
37. IHS Braila BR 125 126 0.8% 31 30 -3.2% 156 156 0.0%
38. Specimed Braila BR 57 65 14.0% 0 0 - 57 65 14.0%
39. Braila County Emergency Hospital BR 17 8 -52.9% 1 0 -100.0% 18 8 -55.6%
40. Avitum Botosani BT 135 225 66.7% 3 13 333.3% 138 238 72.5%
41. Nefromed Dialysis Centers Botosani BT 84 0 -100.0% 11 0 -100.0% 95 0 -100.0%
42. "Mavromati " County Hospital Botosani BT 0 2 - 0 0 - 0 2 -
43. FNC Brasov BV 160 178 11.3% 38 22 -42.1% 198 200 1.0%
44. Arnaldo Medical Clinic Brasov BV 74 92 24.3% 0 4 - 74 94 27.0%
45. Brasov County Clinical Emergency Hospital BV 4 2 -50.0% 1 0 -100.0% 5 2 -60.0%
46. Fagaras Town Hospital BV 14 16 14.3% 1 1 0.0% 15 17 13.3%
47. "ERIKA” Haemodialysis stati on Brasov BV 0 0 - 0 0 - 0 0 -
48. IHS Buzau BZ 139 156 12.2% 70 72 2.9% 209 228 9.1%
49. NEFROCARE DJ Dej CJ 33 37 12.1% 0 0 - 33 37 12.1%
50. Potaissa Renal Care - Turda CJ 76 86 13.2% 0 0 - 76 86 13.2%
51. Rena Clinic Cluj CJ 84 91 8.3% 0 0 - 84 91 8.3%
52. Nefromed Hemodialysis Centers Cluj CJ 188 192 2.1% 10 11 10.0% 198 203 2.5%
62
Dialysis Center County Prevalent pati ents1
HD PD HD + PD
2012 2013 Variance 2012 2013 Variance 2012 2013 Variance2
53. Cluj Children Clinical Emergency Hospital - Nephrolo-gy Department CJ 0 2 - 0 0 - 0 2 -
54. Cluj County Clinical Emergency Hospital CJ 17 6 -64.7% 0 0 - 17 6 -64.7%
55. Cluj-Napoca Town Clinical Hospital CJ 37 40 8.1% 0 0 - 37 40 8.1%
56. IHS Calarasi CL 76 84 10.5% 0 0 - 76 84 10.5%
57. VAMAGO Resita CS 87 82 -5.7% 17 16 -5.9% 104 98 -5.8%
58. Caras Severin County Hospital - Resita CS 4 6 50.0% 2 3 50.0% 6 9 50.0%
59. FNC Constanta CT 158 164 3.8% 3 3 0.0% 161 167 3.7%
60. Nefrocare Med – Medgidia CT 42 42 0.0% 5 3 -40.0% 47 45 -4.3%
61. IHS Constanta CT 20 23 15.0% 6 4 -33.3% 26 27 3.8%
62. Eurodializa – Mangalia CT 27 33 22.2% 0 0 - 27 33 22.2%
63. Constanta County Clinical Emergency Hospital CT 57 68 19.3% 16 11 -31.3% 73 79 8.2%
64. Avitum Sf. Gheorghe CV 43 84 95.3% 1 1 0.0% 44 85 93.2%65. "Dr. Fogolyan Kristof" County Emergency Hospital
Covasna CV 0 6 - 0 0 - 0 6 -
66. Diasys Medical Targoviste DB 69 74 7.2% 0 0 - 69 74 7.2%
67. Renal Care Group Targoviste DB 97 120 23.7% 9 8 -11.1% 106 127 19.8%
68. Dambovita County Emergency Hospital Targoviste DB 16 28 75.0% 9 9 0.0% 25 37 48.0%
69. IHS Craiova DJ 83 102 22.9% 24 22 -8.3% 107 124 15.9%
70. Renamed Dialcare- Craiova DJ 190 202 6.3% 0 0 - 190 202 6.3%
71. Craiova County Clinical Emergency Hospital DJ 63 46 -27.0% 8 6 -25.0% 71 52 -26.8%
72. Avitum Targu-Jiu GJ 137 145 5.8% 9 8 -11.1% 146 153 4.8%
73. Targu Jiu County Emergency Hospital GJ 0 2 - 0 0 - 0 2 -
74. Diaverum Tg. Jiu GJ 59 61 3.4% 4 5 25.0% 63 66 4.8%
75. IHS Galati GL 87 97 11.5% 49 50 2.0% 136 147 8.1%
76. "Sf. Ioan" Clinical Children Emergency Hospital Galati GL 8 7 -12.5% 0 0 - 8 7 -12.5%77. "Sf. Ap. Andrei" County Clinical Emergency Hospital
Galati GL 19 20 5.3% 7 4 -42.9% 26 24 -7.7%
63
Dialysis Center County Prevalent pati ents1
HD PD HD + PD
2012 2013 Variance 2012 2013 Variance 2012 2013 Variance2
78. Renal Care Group Giurgiu GR 71 74 4.2% 0 0 - 71 74 4.2%
79. FNC Deva HD 134 136 1.5% 0 0 - 134 136 1.5%
80. IHS Petrosani HD 60 64 6.7% 1 3 200.0% 61 66 8.2%
81. Hunedoara Deva County Emergency Hospital HD 34 36 5.9% 0 0 - 34 36 5.9%
82. "Wolfgan Steger” Emergency Hospital Petrosani HD 23 17 -26.1% 3 3 0.0% 26 20 -23.1%
83. Diaverum Miercurea Ciuc HR 95 100 5.3% 0 0 - 95 100 5.3%
84. Diaverum Odorheiu Secuiesc HR 47 48 2.1% 1 1 0.0% 48 49 2.1%
85. Harghita County Emergency Hospital Miercurea Ciuc HR 1 2 100.0% 0 0 - 1 2 100.0%
86. Odorheiu Secuiesc Town Hospital HR 1 0 -100.0% 0 0 - 1 0 -100.0%
87. Renal Care Group Slobozia IL 80 92 15.0% 8 6 -25.0% 88 97 10.2%
88. Ialomita County Emergency Hospital Slobozia IL 10 9 -10.0% 0 0 - 10 9 -10.0%
89. FNC - C.I. Parhon Clinical Hospital No. 2 – Iasi IS 216 240 11.1% 54 39 -27.8% 270 279 3.3%
90. NEFROCARE MS – Iasi IS 202 224 10.9% 31 24 -22.6% 233 247 6.0%
91. "Dr. C. I. Parhon" Clinical Hospital IS 20 26 30.0% 0 0 - 20 26 30.0%
92. "Sf. Maria" Clinical Children Emergency Hospital Iasi IS 8 9 12.5% 8 8 0.0% 16 17 6.3%
93. Renamed Medical Service IITurnu Severin MH 166 174 4.8% 12 15 25.0% 178 189 6.2%
94. Drobeta Turnu-Severin Railway Hospital MH 14 10 -28.6% 0 0 - 14 10 -28.6%
95. NEFROCARE SIG Sighetu Marmati ei MM 56 64 14.3% 0 0 - 56 64 14.3%
96. Nefromed Dialysis Centers Baia Mare MM 83 89 7.2% 7 6 -14.3% 90 95 5.6%
97. Baia Mare County Emergency Hospital MM 67 71 6.0% 1 0 -100.0% 68 71 4.4%
98. Avitum Sighisoara MS 34 40 17.6% 0 1 - 34 41 20.6%
99. Avitum Tg. Mures MS 116 117 0.9% 7 8 14.3% 123 125 1.6%
100. HIPARION MED Tg. Mures MS 33 39 18.2% 0 0 - 33 39 18.2%
101. Diaverum Roman NT 62 67 8.1% 2 3 50.0% 64 70 9.4%
102. MEDISS CENTER - Targu Neamt NT 62 68 9.7% 4 3 -25.0% 66 71 7.6%
103. Nefromed Dialysis Centers Piatra Neamt NT 135 132 -2.2% 11 4 -63.6% 146 136 -6.8%
64
Dialysis Center County Prevalent pati ents1
HD PD HD + PD
2012 2013 Variance 2012 2013 Variance 2012 2013 Variance2
104. Neamt County Emergency Hospital Piatra Neamt NT 3 1 -66.7% 0 0 - 3 1 -66.7%
105. Nefrolab Slati na OT 108 137 26.9% 2 4 100.0% 110 141 28.2%
106. Olt Slati na County Emergency Hospital OT 38 26 -31.6% 16 9 -43.8% 54 35 -35.2%
107. IHS Busteni PH 11 14 27.3% 0 0 - 11 14 27.3%
108. PREMIUM MEDICAL CLINIC – Ploiesti PH 0 56 - 0 0 - 0 56 -
109. Nefroclinic Ploiesti PH 206 198 -3.9% 17 16 -5.9% 223 214 -4.0%
110. Prahova County Emergency Hospital Ploiesti PH 103 71 -31.1% 0 0 - 103 71 -31.1%
111. Diaverum Medias SB 47 51 8.5% 6 7 16.7% 53 58 9.4%
112. Diaverum Sibiu SB 153 157 2.6% 6 5 -16.7% 159 162 1.9%
113. Diaverum Sibiu SB 47 49 4.3% 11 10 -9.1% 58 59 1.7%
114. Sibiu County Clinical Emergency Hospital SB 6 7 16.7% 0 0 - 6 7 16.7%
115. NEFROMED SJ Zalau SJ 84 95 13.1% 0 0 - 84 95 13.1%
116. Salaj Zalau County Hospital SJ 4 4 0.0% 0 0 - 4 4 0.0%
117. Nefromed Dialysis Centers Satu Mare SM 118 124 5.1% 29 27 -6.9% 147 151 2.7%
118. Satu Mare County Hospital SM 14 10 -28.6% 0 0 - 14 10 -28.6%
119. Avitum Suceava SV 121 123 1.7% 0 2 - 121 125 3.3%
120. FNC Suceava SV 145 153 5.5% 7 7 0.0% 152 160 5.3%
121. NEFROMED BM Radauti SV 48 53 10.4% 1 1 0.0% 49 52 6.1%122. "Sf. Ioan cel Nou" County Emergency Hospital Suce-
ava SV 18 10 -44.4% 0 0 - 18 10 -44.4%
123. Renal Care Group Tulcea TL 85 81 -4.7% 1 1 0.0% 86 82 -4.7%
124. Tulcea County Emergency Hospital TL 28 35 25.0% 0 0 - 28 35 25.0%
125. Avitum Timisoara TM 92 107 16.3% 6 8 33.3% 98 115 17.3%
126. Nefromed Dialysis Center Timisoara TM 181 170 -6.1% 8 16 100.0% 189 186 -1.6%127. "Louis Turcanu" Children Emergency Hospital TM 0 0 - 1 0 -100.0% 1 0 -100.0%128. Timis County Hospital and Renal transplantati on Clin-
ic Timisoara TM 23 16 -30.4% 0 1 - 23 17 -26.1%
129. Lugoj Town Hospital - Dialysis stati on TM 18 15 -16.7% 1 2 100.0% 19 17 -10.5%
130. Nefromed Dialysis Centers Alexandria TR 128 137 7.0% 0 0 - 128 137 7.0%
65
Dialysis Center County Prevalent pati ents1
HD PD HD + PD
2012 2013 Variance 2012 2013 Variance 2012 2013 Variance2
131. Teleorman County Hospital - Alexandria TR 19 22 15.8% 11 4 -63.6% 30 26 -13.3%
132. IHS Ramnicu Valcea VL 0 0 - 3 6 100.0% 3 6 100.0%
133. RENAMED NEFRODIAMED Ramnicu Valcea VL 134 158 17.9% 0 0 - 134 158 17.9%
134. Valcea County Hospital Ramnicu Valcea VL 43 46 7.0% 8 5 -37.5% 51 51 0.0%
135. IHS Focsani VN 144 161 11.8% 54 55 1.9% 198 216 9.1%136. "Sf. Pantelimon" Vrancea County Emergency Hospital,
Focsani VN 12 11 -8.3% 1 2 100.0% 13 13 0.0%
137. Med Center Clinic – Vaslui VS 82 103 25.6% 15 9 -40.0% 97 111 14.4%
138. Nefromed Dialysis Centers Barlad VS 105 110 4.8% 0 6 - 105 116 10.5%
139. "Elena Beldiman" Barlad Town Emergency Hospital VS 3 11 266.7% 0 0 - 3 11 266.7%
Romania 9.551 10.322 8.1% 919 854 -7.1% 10.470 11.158 6.6%1 - Pati ents registered on 31.12.2012 and 31.12.20132 - Variance in percentage 31.12.2013 vs. 31.12.2012
66
Appendix 7. Prevalent and incident dialysis pati ents, non-preempti ve transplanted or deceased pati ents in dialysis centers in Romania in 2013 (in the alphabeti cal order of the counti es)
Dialysis center County Prevalent pati ents* Newly-included pati ents Deaths
HD PD PD/HD HD+DP HD PD PD/HD HD+DP TR
No No % No No No % No % No % No %
1. Nefromed Dialysis Centers - Alba-Iulia AB 178 3 1.7% 181 11 0 0.0% 11 6.1% 1 0.6% 18 9.9%2. Alba-Iulia County Emergency Hospital - Haemodialy-
sis department AB 3 0 0.0% 3 23 0 0.0% 23 920.0% 0 0.0% 0 0.0%
3. Fresenius NephroCare Pitesti AG 178 10 5.7% 188 0 0 - 0 0.0% 0 0.0% 23 12.3%
4. Nefrocare CL - Campulung AG 50 0 0.0% 50 0 0 - 0 0.0% 1 2.0% 6 12.0%
5. Arges - Pitesti County Hospital AG 77 1 0.8% 78 27 1 3.7% 28 36.1% 0 0.0% 16 20.6%
6. Hemo-Vest - Arad AR 156 5 3.1% 161 0 0 - 0 0.0% 2 1.2% 21 13.1%
7. Arad County Clinical Emergency Hospital AR 31 0 0.8% 31 74 0 0.0% 74 240.7% 0 0.0% 28 91.1%
8. IHS "Sf. Ioan" Bucharest B 153 37 24.4% 191 3 4 133.3% 7 3.7% 0 0.0% 28 14.7%
9. CMDTAMP Bucharest B 38 0 0.2% 38 1 1 100.0% 2 5.3% 0 0.0% 5 13.2%
10. Fresenius NephroCare "Dr. Carol Davila” - Bucharest B 347 16 4.5% 362 0 0 - 0 0.0% 3 0.8% 13 3.6%
11. Fundeni Clinical Insti tute - Pediatric Dialysis B 8 8 97.8% 15 2 0 0.0% 2 13.2% 0 0.0% 0 0.0%
12. Fundeni Clinical Insti tute - Renal transplantati on B 8 0 0.0% 8 49 0 0.0% 49 612.5% 112 1400.0% 0 0.0%13. "N. Paulescu” Insti tute for Nutriti on and Metabolic
Diseases B 35 8 22.9% 43 36 5 13.9% 41 95.5% 0 0.0% 11 25.6%
14. IHS - "Sf. Pantelimon" Bucharest B 127 4 3.2% 131 2 0 0.0% 2 1.5% 2 1.5% 17 13.0%
15. IHS – Fundeni B 87 44 50.8% 131 1 0 0.0% 1 0.8% 1 0.8% 9 6.9%
16. Diaverum - Bucharest – Industriilor B 132 14 10.3% 146 0 0 - 0 0.0% 2 1.4% 15 10.3%
17. Diaverum - Bucuresti - Splai Independentei B 151 4 2.9% 155 0 0 - 0 0.0% 0 0.0% 20 12.9%
18. DIA MEDICAL PORT - Bucharest B 80 0 0.0% 80 0 0 - 0 0.0% 4 5.0% 7 8.7%
19. Gral Medical - Bucharest B 87 0 0.0% 87 0 0 - 0 0.0% 0 0.0% 0 0.0%
20. Nefro Care Center - Bucharest B 93 4 3.9% 97 0 0 - 0 0.0% 0 0.0% 9 9.3%21. "Dr. Carol Davila" Clinical Nephrology Hospital – Bu-
charest B 32 12 37.7% 44 172 16 9.3% 188 428.9% 0 0.0% 11 25.1%
22. "Sf. Ioan" Clinical Emergency Hospital Bucharest B 18 0 0.0% 18 110 0 0.0% 110 614.0% 0 0.0% 20 111.6%23. "Grigore Alexandrescu" Children Clinical Emergency
Hospital B 0 0 - 0 0 0 - 0 - 0 - 0 -
24. Floreasca Clinical Emergency Hospital Bucharest B 17 4 23.0% 21 24 1 4.2% 25 119.5% 1 4.8% 11 52.6%
25. Fundeni Clinical Insti tute - Nephrology B 11 12 109.1% 23 43 14 32.6% 57 247.8% 0 0.0% 4 17.4%
67
Dialysis center County Prevalent pati ents* Newly-included pati ents Deaths
HD PD PD/HD HD+DP HD PD PD/HD HD+DP TR
No No % No No No % No % No % No %26. "Marie Curie" Children Emergency Hospital Bucha-
rest B 10 0 0.0% 10 4 0 0.0% 4 40.0% 0 0.0% 0 0.0%
27. SUUB University Emergency Hospital Bucharest B 44 2 4.6% 46 133 3 2.3% 136 298.9% 0 0.0% 44 96.7%
28. Fresenius NephroCare Bacau BC 202 28 14.0% 230 14 1 7.1% 15 6.5% 6 2.6% 32 13.9%
29. MALP Moinesti BC 9 0 0.0% 9 0 0 - 0 0.0% 0 0.0% 1 11.0%
30. Renal Med Bacau- Onesti BC 61 0 0.0% 61 2 0 0.0% 2 3.3% 0 0.0% 5 8.2%
31. Bacau County Emergency Hospital BC 19 1 5.8% 20 19 10 52.6% 29 147.5% 0 0.0% 5 25.4%
32. Moinesti Dialysis stati on BC 30 0 0.0% 30 2 0 0.0% 2 6.7% 0 0.0% 9 30.2%
33. Fresenius NephroCare Oradea BH 198 0 0.0% 198 53 0 0.0% 53 26.8% 3 1.5% 51 25.8%
34. Renamed Nefrodial - Oradea BH 164 19 11.5% 183 52 5 9.6% 57 31.1% 5 2.7% 33 18.0%
35. Diaverum - Bistrita BN 94 0 0.0% 94 0 0 - 0 0.0% 3 3.2% 13 13.8%
36. Bistrita Nasaud County Emergency Hospital BN 25 0 0.0% 25 35 0 0.0% 35 141.9% 0 0.0% 10 40.5%
37. IHS – Braila BR 127 32 24.8% 159 0 1 - 1 0.6% 0 0.0% 10 6.3%
38. Specimed – Braila BR 61 0 0.0% 61 0 0 - 0 0.0% 0 0.0% 0 0.0%
39. Braila County Emergency Hospital BR 14 1 6.0% 15 54 8 14.8% 62 418.0% 0 0.0% 16 107.9%
40. Avitum – Botosani BT 208 12 5.8% 220 4 0 0.0% 4 1.8% 4 1.8% 22 10.0%
41. Nefromed Dialysis Centers - Botosani BT 13 2 13.8% 15 0 0 - 0 0.0% 0 0.0% 2 13.2%
42. "Mavromati " County Hospital Botosani BT 3 0 0.0% 3 24 1 4.2% 25 833.3% 0 0.0% 0 0.0%
43. Fresenius NephroCare Brasov BV 170 29 16.9% 198 3 0 0.0% 3 1.5% 6 3.0% 20 10.1%
44. Arnaldo Medical Clinic Brasov BV 88 2 2.3% 90 17 2 11.8% 19 21.1% 0 0.0% 4 4.4%
45. Brasov County Clinical Emergency Hospital BV 7 0 1.2% 7 61 1 1.6% 62 907.3% 0 0.0% 7 102.4%
46. Fagaras Town Hospital BV 16 1 6.3% 17 1 0 0.0% 1 5.9% 0 0.0% 6 35.3%
47. "ERIKA” Haemodialysis stati on Brasov BV 0 0 - 0 0 0 - 0 - 0 - 0 -
48. IHS - Buzau BZ 150 73 48.7% 223 34 10 29.4% 44 19.7% 0 0.0% 29 13.0%
49. NEFROCARE DJ - Dej CJ 37 0 0.0% 37 0 0 - 0 0.0% 1 2.7% 7 18.7%
50. Potaissa Renal Care - Turda CJ 82 0 0.0% 82 3 0 0.0% 3 3.7% 0 0.0% 12 14.7%
51. Rena Clinic Cluj CJ 92 0 0.0% 92 0 0 - 0 0.0% 2 2.2% 0 0.0%
52. Nefromed Hemodialysis Centers - Cluj CJ 186 11 5.8% 197 0 0 - 0 0.0% 2 1.0% 27 13.7%
53. Cluj Children Clinical Emergency Hospital CJ 2 0 0.0% 2 1 1 100.0% 2 100.0% 0 0.0% 0 0.0%
54. Cluj County Clinical Emergency Hospital CJ 10 0 0.9% 10 76 1 1.3% 77 796.6% 0 0.0% 0 0.0%
68
Dialysis center County Prevalent pati ents* Newly-included pati ents Deaths
HD PD PD/HD HD+DP HD PD PD/HD HD+DP TR
No No % No No No % No % No % No %
55. Cluj-Napoca Town Clinical Hospital CJ 39 0 0.4% 39 4 0 0.0% 4 10.2% 0 0.0% 4 10.2%
56. IHS – Calarasi CL 79 0 0.0% 79 6 0 0.0% 6 7.6% 0 0.0% 2 2.5%
57. VAMAGO - Resita CS 85 16 18.9% 102 2 1 50.0% 3 3.0% 2 2.0% 18 17.7%
58. Caras Severin County Hospital - Resita CS 6 2 35.5% 9 4 3 75.0% 7 81.6% 0 0.0% 9 104.9%
59. Fresenius NephroCare Constanta CT 161 4 2.2% 165 0 0 - 0 0.0% 1 0.6% 10 6.1%
60. Nefrocare Med - Medgidia CT 43 4 8.4% 46 0 0 - 0 0.0% 0 0.0% 11 23.8%
61. IHS – Constanta CT 23 5 21.2% 28 0 0 - 0 0.0% 1 3.6% 2 7.1%
62. Eurodializa - Mangalia CT 34 0 0.0% 34 0 0 - 0 0.0% 0 0.0% 3 8.8%
63. Constanta County Clinical Emergency Hospital CT 65 12 18.9% 77 92 2 2.2% 94 122.6% 0 0.0% 31 40.4%
64. Avitum - Sf. Gheorghe CV 62 1 1.6% 63 5 0 0.0% 5 8.0% 1 1.6% 7 11.1%65. "Dr. Fogolyan Kristof" County Emergency Hospital
Covasna CV 1 0 6.3% 1 10 1 10.0% 11 776.5% 0 0.0% 3 211.8%
66. Diasys Medical - Targoviste DB 69 0 0.0% 69 0 0 - 0 0.0% 0 0.0% 8 11.5%
67. Renal Care Group - Targoviste DB 113 9 8.0% 122 0 0 - 0 0.0% 1 0.8% 0 0.0%
68. Dambovita County Emergency Hospital Targoviste DB 17 9 50.5% 25 61 1 1.6% 62 244.7% 0 0.0% 1 3.9%
69. IHS – Craiova DJ 93 22 23.7% 115 0 0 - 0 0.0% 0 0.0% 17 14.7%
70. Renamed Dialcare - Craiova DJ 200 0 0.0% 200 0 0 - 0 0.0% 1 0.5% 5 2.5%
71. Craiova County Clinical Emergency Hospital DJ 57 7 11.9% 63 103 5 4.9% 108 170.3% 0 0.0% 20 31.5%
72. Avitum - Targu-Jiu GJ 143 9 6.2% 152 20 2 10.0% 22 14.5% 1 0.7% 23 15.1%
73. Diaverum - Tg. Jiu GJ 62 4 5.6% 66 0 0 - 0 0.0% 2 3.1% 5 7.6%
74. Targu Jiu County Emergency Hospital GJ 1 0 0.0% 1 11 0 0.0% 11 1100.0% 0 0.0% 0 0.0%
75. Dialysis stati on of the Tg. Carbunesti Town Hospital GJ 0 0 - 0 0 1 - 1 1200.0% 0 0.0% 0 0.0%
76. IHS – Galati GL 93 49 52.2% 142 0 0 - 0 0.0% 1 0.7% 16 11.3%
77. "Sf. Ioan" Clinical Children Emergency Hospital Galati GL 7 0 5.6% 8 0 0 - 0 0.0% 1 12.8% 0 0.0%78. "Sf. Ap. Andrei" County Clinical Emergency Hospital
Galati GL 21 6 26.7% 27 20 12 60.0% 32 120.8% 0 0.0% 11 41.5%
79. Renal Care Group - Giurgiu GR 71 0 0.0% 71 0 0 - 0 0.0% 0 0.0% 12 16.8%
80. Fresenius NephroCare Deva HD 135 0 0.0% 135 0 0 - 0 0.0% 1 0.7% 19 14.1%
81. IHS Petrosani HD 63 2 3.2% 65 0 0 - 0 0.0% 2 3.1% 9 14.0%
82. Hunedoara County Emergency Hospital - Deva HD 36 0 0.0% 36 56 0 0.0% 56 155.6% 0 0.0% 0 0.0%
83. "Wolfgan Steger” Emergency Hospital Petrosani HD 18 3 14.6% 20 32 3 9.4% 35 172.8% 1 4.9% 6 29.6%
69
Dialysis center County Prevalent pati ents* Newly-included pati ents Deaths
HD PD PD/HD HD+DP HD PD PD/HD HD+DP TR
No No % No No No % No % No % No %
84. Diaverum - Miercurea Ciuc HR 101 0 0.0% 101 0 0 - 0 0.0% 1 1.0% 2 2.0%
85. Diaverum - Odorheiu Secuiesc HR 45 1 2.0% 46 0 0 - 0 0.0% 2 4.3% 6 13.0%
86. Harghita County Emergency Hospital Miercurea Ciuc HR 2 0 0.0% 2 17 0 0.0% 17 1020.0% 0 0.0% 0 0.0%
87. Odorheiu Secuiesc Town Hospital HR 1 0 0.0% 1 5 0 0.0% 5 1000.0% 0 0.0% 1 200.0%
88. Renal Care Group – Slobozia IL 86 6 6.4% 91 0 0 - 0 0.0% 0 0.0% 7 7.7%
89. Ialomita County Emergency Hospital Slobozia IL 11 0 0.0% 11 18 0 0.0% 18 167.4% 0 0.0% 0 0.0%
90. Fresenius NephroCare - „CI Parhon” Iasi IS 230 47 20.3% 276 6 5 83.3% 11 4.0% 4 1.4% 33 12.0%
91. NEFROCARE MS – Iasi IS 215 27 12.7% 242 2 0 0.0% 2 0.8% 5 2.1% 11 4.5%
92. "Dr. C. I. Parhon" Clinical Hospital Iasi IS 26 0 0.3% 26 261 1 0.4% 262 1010.9% 0 0.0% 21 81.0%
93. "Sf. Maria" Clinical Children Emergency Hospital Iasi IS 9 8 91.4% 17 5 1 20.0% 6 35.8% 0 0.0% 1 6.0%
94. Renamed Medical Service II - Turnu Severin MH 172 14 8.1% 186 36 1 2.8% 37 19.9% 3 1.6% 26 14.0%
95. Drobeta Turnu-Severin Railway Hospital MH 11 0 0.8% 11 0 0 - 0 0.0% 0 0.0% 5 46.5%
96. NEFROCARE SIG - Sighetu Marmati ei MM 61 0 0.0% 61 0 0 - 0 0.0% 0 0.0% 2 3.3%
97. Nefromed Dialysis Centers - Baia Mare MM 85 7 7.9% 91 1 0 0.0% 1 1.1% 0 0.0% 3 3.3%
98. Baia Mare County Emergency Hospital MM 72 0 0.0% 72 43 0 0.0% 43 59.6% 0 0.0% 13 18.0%
99. Avitum - Sighisoara MS 38 0 0.7% 38 5 0 0.0% 5 13.2% 1 2.6% 3 7.9%
100. Avitum Tg. Mures MS 118 7 6.1% 125 6 0 0.0% 6 4.8% 1 0.8% 8 6.4%
101. HIPARION MED Targu Mures MS 37 0 0.0% 37 7 0 0.0% 7 19.0% 1 2.7% 3 8.1%
102. Diaverum - Roman NT 64 3 4.2% 67 0 0 - 0 0.0% 0 0.0% 9 13.5%
103. MEDISS CENTER - Targu Neamt NT 71 4 4.9% 75 0 0 - 0 0.0% 1 1.3% 16 21.5%
104. Nefromed Dialysis Centers - Piatra Neamt NT 135 6 4.6% 141 1 0 0.0% 1 0.7% 2 1.4% 16 11.3%
105. Neamt County Emergency Hospital - Piatra Neamt NT 3 0 0.0% 3 23 0 0.0% 23 766.7% 0 0.0% 11 366.7%
106. Nefrolab - Slati na OT 129 3 2.6% 133 1 0 0.0% 1 0.8% 0 0.0% 17 12.8%
107. Olt Slati na County Emergency Hospital OT 28 11 38.7% 39 29 3 10.3% 32 82.4% 0 0.0% 11 28.3%
108. IHS Busteni PH 12 0 0.0% 12 0 0 - 0 0.0% 0 0.0% 1 8.3%
109. PREMIUM MEDICAL CLINIC - Ploiesti PH 37 0 0.0% 37 0 0 - 0 0.0% 0 0.0% 9 24.5%
110. Nefroclinic - Ploiesti PH 199 17 8.6% 216 0 3 - 3 1.4% 0 0.0% 22 10.2%
111. Prahova County Emergency Hospital Ploiesti PH 81 0 0.2% 81 67 2 3.0% 69 85.5% 0 0.0% 30 37.2%
112. Diaverum - Medias SB 47 8 16.4% 55 0 2 - 2 3.6% 0 0.0% 10 18.2%
113. Diaverum - Sibiu SB 159 5 3.0% 163 0 0 - 0 0.0% 5 3.1% 11 6.7%
70
Dialysis center County Prevalent pati ents* Newly-included pati ents Deaths
HD PD PD/HD HD+DP HD PD PD/HD HD+DP TR
No No % No No No % No % No % No %
114. Diaverum – Sibiu SB 47 11 23.3% 58 0 0 - 0 0.0% 1 1.7% 2 3.5%
115. Sibiu County Clinical Emergency Hospital SB 9 0 0.9% 9 67 1 1.5% 68 762.6% 0 0.0% 15 168.2%
116. NEFROMED SJ - Zalau SJ 89 0 0.0% 89 1 0 0.0% 1 1.1% 1 1.1% 14 15.8%
117. Salaj - Zalau County Hospital SJ 3 0 0.0% 3 27 0 0.0% 27 1012.5% 0 0.0% 4 150.0%
118. Nefromed Dialysis Centers - Satu Mare SM 122 28 22.9% 150 3 0 0.0% 3 2.0% 4 2.7% 7 4.7%
119. Satu Mare County Hospital SM 12 0 2.0% 13 24 3 12.5% 27 214.6% 5 39.7% 12 95.4%
120. Avitum - Suceava SV 120 1 1.1% 122 0 0 - 0 0.0% 0 0.0% 18 14.8%
121. Fresenius NephroCare Suceava SV 152 8 4.9% 159 1 0 0.0% 1 0.6% 0 0.0% 5 3.1%
122. NEFROMED BM - Radauti SV 54 1 1.9% 55 0 0 - 0 0.0% 0 0.0% 3 5.5%123. "Sf. Ioan cel Nou" County Emergency Hospital Suce-
ava SV 14 0 0.0% 14 132 0 0.0% 132 937.3% 0 0.0% 30 213.0%
124. Renal Care Group – Tulcea TL 83 1 1.2% 84 0 0 - 0 0.0% 1 1.2% 6 7.1%
125. Tulcea County Emergency Hospital TL 30 0 0.0% 30 21 0 0.0% 21 70.8% 0 0.0% 0 0.0%
126. Avitum - Timisoara TM 101 7 6.7% 108 1 1 100.0% 2 1.9% 1 0.9% 16 14.8%
127. Nefromed Dialysis Center - Timisoara TM 174 13 7.5% 187 0 2 - 2 1.1% 2 1.1% 18 9.6%
128. "Louis Turcanu" Children Emergency Hospital TM 0 0 - 0 0 0 - 0 - 0 - 0 -
129. Timis County Hospital TM 19 1 4.5% 19 62 2 3.2% 64 329.6% 6 30.9% 16 82.4%
130. Lugoj Town Hospital TM 18 1 6.8% 20 2 0 0.0% 2 10.3% 0 0.0% 0 0.0%
131. Nefromed Dialysis Centers - Alexandria TR 132 0 0.0% 132 0 0 - 0 0.0% 0 0.0% 28 21.2%
132. Teleorman County Hospital – Alexandria TR 20 9 42.9% 29 48 3 6.3% 51 178.4% 0 0.0% 3 10.5%
133. IHS - Ramnicu Valcea VL 0 5 - 5 0 4 - 4 80.0% 0 0.0% 0 0.0%
134. RENAMED NEFRODIAMED - Ramnicu Valcea VL 152 0 0.0% 152 0 0 - 0 0.0% 2 1.3% 17 11.2%
135. Vâlcea County Hospital - Râmnicu Vâlcea VL 45 7 15.1% 52 44 1 2.3% 45 87.4% 0 0.0% 9 17.5%
136. IHS – Focsani VN 149 53 35.7% 202 0 0 - 0 0.0% 0 0.0% 13 6.4%137. County Emergency Hospital "Sf. Pantelimon" Vrancea
- Focsani VN 18 2 11.1% 20 45 3 6.7% 48 240.0% 0 0.0% 1 5.0%
138. Med Center Clinic - Vaslui VS 94 12 12.3% 106 0 0 - 0 0.0% 1 0.9% 9 8.5%
139. Nefromed Dialysis Centers – Barlad VS 109 6 5.5% 115 0 0 - 0 0.0% 0 0.0% 18 15.7%140. "Elena Beldiman" Emergency Hospital of the Town
Barlad VS 5 0 0.0% 5 37 0 0.0% 37 792.9% 0 0.0% 6 128.6%
Romania 10.022 878 8.8% 10900 2.644 155 5.9% 2.799 25.7% 227 2.1% 1.487 13.6%
* Monthly average of prevalent pati ents in 2013
71
Appendix 8. Haemodialysis centers ordered increasingly by the standardized mortality rati o (SMR)
Hemodialysis center Prevalent pati ents* SMR CI 95% Signifi cance†
Fresenius NephroCare Pitesti - Dialysis center 130 0.39 0.15 0.62 Low
Valcea County Hospital - Dialysis center Ramnicu Valcea 36 0.35 -0.05 0.74 Low
S.C. NEFROCARE SIG S.R.L. - Dialysis center Sighetu Marmati ei 47 0.29 -0.01 0.59 Low
Potaissa Renal Care - Turda - Dialysis center 45 0.27 0 0.54 Low
Rena Clinic Cluj 76 0.14 0.04 0.25 Low
Renal Care Group - Dialysis center Targoviste 94 0.13 0.04 0.23 Low
NEFROCARE MS Dialysis Center - Iasi 154 0.58 0.25 0.9 Low
Internati onal Healthcare Systems S.A - "Sf. Pantelimon" Bucharest 92 0.56 0.15 0.96 Low
S.C. Nefrolab S.R.L. - Dialysis center Slati na 87 0.56 0.15 0.96 Low
Fresenius NephroCare Bacau - Dialysis center 167 0.49 0.21 0.76 Low
SC Diaverum Romania SRL - Roman Unit 49 0.49 0.02 0.96 Low
Fresenius NephroCare "Dr. Carol Davila” - Dialysis center Bucharest 327 0.62 0.38 0.86 Low
Olt County Emergency Hospital - Haemodialysis center Slati na 35 5.45 -1.22 12.12 Similar
Hunedoara County Emergency Hospital - Dialysis center Deva 26 0.44 -0.14 1.02 Similar
S.C. Med Center Clinic SRL – Vaslui 68 0.57 0.08 1.05 Similar
SC Diaverum Romania SRL - Miercurea Ciuc Unit 89 0.59 0.15 1.04 Similar
Internati onal Healthcare Systems S.A. - Dialysis center Braila 98 0.63 0.19 1.08 Similar
S.C. Nefromed Dialysis Centers SRL - Dialysis center Piatra Neamt 117 0.65 0.23 1.07 Similar
SC Diaverum Romania SRL- Dialysis center Sibiu 38 0.67 -0.09 1.44 Similar
S.C. Renamed Dialcare SRL- Craiova 152 0.69 0.29 1.1 Similar
SC Diaverum Romania SRL - Unit Tg. Jiu 55 0.7 0.04 1.37 Similar
Internati onal Healthcare Systems S.A - Dialysis center Craiova 75 0.79 0.1 1.47 Similar
CMDTAMP Bucharest 32 0.8 -0.19 1.8 Similar
Fresenius NephroCare Brasov - Dialysis center 130 0.8 0.3 1.29 Similar
Avitum SRL - Dialysis center Timisoara 72 0.81 0.17 1.45 Similar
Nefrocare Med Dialysis Center – Medgidia 30 0.82 -0.21 1.84 Similar
72
Hemodialysis center Prevalent pati ents* SMR CI 95% Signifi cance†
SC Diaverum Romania SRL - Unit Bucharest – Industriilor 118 0.83 0.31 1.36 Similar
Constanta County Clinical Hospital - Haemodialysis center 47 0.84 -0.03 1.7 Similar
Fresenius NephroCare Deva - Dialysis center 127 0.84 0.34 1.34 Similar
Avitum SRL - Dialysis center Sighisoara 33 0.86 -0.25 1.97 Similar
S.C. Nefromed Dialysis Center SRL - Dialysis center Timisoara 156 0.87 0.39 1.35 Similar
S.C. Clinica Medicala Arnaldo SRL Brasov 62 0.87 0.07 1.67 Similar
Renal Care Group - Dialysis center Giurgiu 59 0.87 0.07 1.67 Similar
S.C. RENAMED NEFRODIAMED SRL - Ramnicu Valcea 105 0.95 0.31 1.59 Similar
S.C. Nefroclinic SRL - Dialysis center Ploiesti 164 0.97 0.43 1.51 Similar
S.C. Renamed Medical Service II SRL- Dialysis center Turnu Severin 154 0.98 0.45 1.51 Similar
Renal Care Group - Dialysis center Slobozia 65 1 0.12 1.88 Similar
Fresenius NephroCare Constanta - Dialysis center 150 1.02 0.41 1.63 Similar
S.C. Nefromed Dialysis Centers SRL - Dialysis center Alba-Iulia 128 1.03 0.38 1.67 Similar
Internati onal Healthcare System S.A. - Dialysis center Focsani 131 1.08 0.42 1.74 Similar
Avitum SRL - Haemodialysis center Tg. Mures 118 1.13 0.39 1.87 Similar
S.C. VAMAGO SRL - Dialysis center Resita 75 1.18 0.23 2.12 Similar
S.C. Nefromed Hemodialysis Centers SRL - Dialysis center Cluj 162 1.19 0.53 1.84 Similar
S.C. Renamed Nefrodial SRL – Oradea 146 1.24 0.54 1.94 Similar
Renal Care Group - Dialysis center Tulcea 75 1.26 0.21 2.3 Similar
SC Diaverum Romania SRL - Sibiu Unit 132 1.34 0.5 2.17 Similar
Internati onal Healthcare Systems S.A - Dialysis center Calarasi 63 1.34 0.1 2.58 Similar
University Emergency Hospital Bucharest - Haemodialysis center SUUB 19 1.35 -0.83 3.53 Similar
Tulcea County Emergency Hospital - Dialysis center 17 1.45 -0.98 3.89 Similar
Avitum SRL - Dialysis center Targu-Jiu 119 1.48 0.54 2.43 Similar
Fresenius NephroCare Oradea - Dialysis center 175 1.52 0.74 2.31 Similar
Moinesti Dialysis stati on 27 1.53 -0.61 3.67 Similar
SC HIPARION MED SRL Targu Mures 28 1.53 -0.62 3.69 Similar
73
Hemodialysis center Prevalent pati ents* SMR CI 95% Signifi cance†
Baia Mare County Emergency Hospital - Haemodialysis center Baia Mare 45 1.54 -0.14 3.22 Similar
S.C. NEFROMED SJ S.R.L. - Dialysis center Zalau 65 1.58 0.2 2.96 Similar
SC Diaverum Romania SRL - Bistrita Unit 61 1.59 0.11 3.07 Similar
SC Diaverum Romania SRL - Odorheiu Secuiesc Unit 45 1.6 -0.17 3.37 Similar
S.C. Nefromed Dialysis Centers SRL- Dialysis center Barlad 90 1.61 0.34 2.87 Similar
Floreasca Clinical Emergency Hospital Bucharest - Dialysis center 20 1.65 -0.74 4.04 Similar
Fresenius NephroCare Suceava - Dialysis center 120 1.66 0.58 2.75 Similar
Avitum SRL - Dialysis center Botosani 130 1.71 0.65 2.77 Similar
IHS "Sf. Ioan" Dialysis Center Bucharest 162 1.72 0.73 2.71 Similar
S.C. Nefromed Dialysis Centers SRL- Dialysis center Alexandria 101 1.73 0.49 2.97 Similar
S.C. Nefromed Dialysis Centers SRL - Dialysis center Baia Mare 80 1.75 0.31 3.19 Similar
Cluj-Napoca Town Clinical Hospital - Hemodialysis center 39 1.77 -0.3 3.84 Similar
Avitum SRL - Sf. Gheorghe Dialysis Center 47 1.79 -0.13 3.7 Similar
Internati onal Healthcare System S.A. - Dialysis center Buzau 128 1.8 0.65 2.94 Similar
Prahova County Emergency Hospital - Haemodialysis center Ploiesti 90 1.8 0.43 3.17 Similar
"Sf. Ap. Andrei" Galati County Clinical Emergency Hospital - Dialysis center 15 1.84 -1.62 5.3 Similar
S.C. Nefromed Dialysis Centers SRL - Dialysis center Satu Mare 112 1.84 0.62 3.06 Similar
S.C. Renal Med SRL Bacau- Dialysis center Onesti 52 1.85 -0.01 3.71 Similar
Nefrocare CL Dialysis Center - Campulung 26 1.87 -1.02 4.75 Similar
S.C. Nefromed Dialysis Centers SRL - Dialysis center Botosani 80 1.89 0.35 3.43 Similar
S.C. Nefro Care Center - Dialysis center Bucuresti 56 1.89 0.09 3.7 Similar
Braila County Emergency Hospital - Dialysis center 27 1.91 -0.68 4.5 Similar
Internati onal Healthcare System S.A. - Dialysis center Petrosani 57 1.92 0.18 3.66 Similar
Avitum SRL - Dialysis center Suceava 110 1.93 0.57 3.29 Similar
Craiova County Clinical Emergency Hospital - Dialysis center 65 1.97 0.26 3.67 Similar
SC Diaverum Romania SRL - Unit Bucharest - Splai Independentei 113 2.02 0.66 3.38 Similar
Internati onal Healthcare Systems S.A. - Dialysis center Galati 67 2.08 0.22 3.94 Similar
74
Hemodialysis center Prevalent pati ents* SMR CI 95% Signifi cance†
S.C. NEFROMED BM S.R.L. - Dialysis center Radauti 44 2.09 -0.15 4.32 Similar
S.C. Diasys Medical SRL - Dialysis center Targoviste 54 2.12 0.1 4.14 Similar
“Dr Carol Davila” Clinical Nephrology Hospital - Bucharest - Dialysis department 12 2.15 -2.21 6.51 Similar
Internati onal Healthcare Systems S.A - Dialysis center Fundeni 63 2.16 0.19 4.13 Similar
S.C. Eurodializa SRL – Mangalia 26 2.2 -1 5.39 Similar
S.C. Hemo-Vest SRL – Arad 119 2.28 0.84 3.71 Similar
Petrosani Emergency Hospital - "Wolfgan Steger” Haemodialysis center 11 2.43 -2.81 7.67 Similar
"Marie Curie" Children Emergency Hospital Bucharest 9 2.49 -5.21 10.2 Similar
Bistrita Nasaud County Emergency Hospital - Haemodialysis center 16 2.54 -2.04 7.12 Similar
IHS Busteni Dialysis Center 11 2.58 -3.16 8.31 Similar
Satu Mare County Hospital - Dialysis center 6 2.64 -5.76 11.04 Similar
S.C. MEDISS CENTER SRL - Targu Neamt 54 2.69 -0.04 5.41 Similar
Fagaras Town Hospital - Dialysis center 14 2.75 -2.41 7.92 Similar
"Sf. Maria" Clinical Children Emergency Hospital Iasi 7 2.75 -6.19 11.69 Similar
Bacau County Emergency Hospital - Haemodialysis stati on 42 2.85 -0.29 5.99 Similar
"Elena Beldiman” Town Emergency Hospital - Dialysis center Barlad 8 2.86 -3.85 9.58 Similar
Teleorman County Hospital - Dialysis center Alexandria 17 3.09 -2.23 8.41 Similar
Sibiu County Clinical Emergency Hospital - Dialysis stati on 8 3.17 -4.65 11 Similar
S.C. NEFROCARE DJ SRL - Dialysis center Dej 31 3.24 -0.8 7.28 Similar
SC Diaverum Romania SRL - Medias Unit 43 3.65 -0.47 7.76 Similar
Caras Severin County Hospital - Resita 4 3.72 -10.35 17.8 Similar
Timis County Hospital - Dialysis and renal transplantati on center Timisoara 26 3.9 -1.44 9.24 Similar
County Emergency Hospital "Sf. Pantelimon" Vrancea - Dialysis center Focsani 10 3.96 -4.95 12.87 Similar
Drobeta Turnu-Severin Railway Hospital - Dialysis Center 17 4.06 -3.11 11.23 Similar
Lugoj Town Hospital - Dialysis stati on 14 4.24 -4.33 12.82 Similar
Arad County Clinical Emergency Hospital - Dialysis center 24 4.32 -1.19 10.55 Similar
Ploiesti General Railway Hospital - Dialysis stati on 13 4.51 -4.88 13.91 Similar
75
* Prevalent haemodialysis pati ents on 31.12.2012† Low – Standardized mortality rati o (SMR) strictly below 1 (indicates a mortality rate lower than that of the reference cohort); High – SMR strictly above 1 (indicates a mortality rate higher than that of the reference cohort); Similar – SMR not diff erent from 1 (indicates a mortality rate similar to that of the reference cohort); NA – not assessed (too small number of pati ents or too small observati on interval)
Hemodialysis center Prevalent pati ents* SMR CI 95% Signifi cance†
Brasov County Clinical Emergency Hospital - Dialysis center 20 5.11 -3.45 13.68 Similar
Fresenius NephroCare SRL - „CI Parhon” Clinical Hospital No. 2 Iasi 205 2.47 1.25 3.7 High
"Mavromati " County Hospital Botosani - Dialysis center 1 NE NE NE NE
"N. Paulescu” Insti tute for Nutriti on and Metabolic Diseases - Dialysis center 11 NE NE NE NE
Fundeni Clinical Insti tute - Dialysis center 1 NE NE NE NEFundeni Clinical Insti tute - Pediatric department, Nephrology department and the Pediatric dialysis department 6 NE NE NE NE
Dambovita County Emergency Hospital - Hemodialysis center Targoviste 10 NE NE NE NE
Hunedoara Town Hospital - Haemodialysis center 1 NE NE NE NE
Ialomita County Emergency Hospital - Hemodialysis center Slobozia 7 NE NE NE NE
Mehedinti County Hospital - Dialysis center 2 NE NE NE NE
Neamt County Emergency Hospital - Dialysis center Piatra Neamt 1 NE NE NE NE
Arges County Hospital - Dialysis center Pitesti 47 NE NE NE NE
"Sf. Ioan cel Nou" County Emergency Hospital Suceava - Dialysis center 2 NE NE NE NE
"Louis Turcanu" Pediatric Emergency Hospital - Pedriatrics I - Haemodialysis lab 1 NE NE NE NE
Sinaia Town Hospital - Dialysis department 1 NE NE NE NE
Oradea Railway Hospital 1 NE NE NE NE
Giurgiu County Hospital - Dialysis center 1 NE NE NE NE
"Sf. Ioan" Clinical Children Emergency Hospital Galati 7 NE NE NE NE
S.C. Specimed S.A.- Dialysis center Braila 39 NE NE NE NE
S.C. Gral Medical SRL- Dialysis center Bucharest 60 NE NE NE NE
Fundeni Clinical Insti tute - Renal transplantati on department 15 NE NE NE NE
"Sf. Ioan" Clinical Emergency Hospital - Bucharest - Dialysis department 1 NE NE NE NE
Internati onal Healthcare System S.A. - Dialysis center Constanta 9 NE NE NE NE
DIA MEDICAL PORT - Bucharest 26 NE NE NE NE
S.C. MALP srl Moinesti - Dialysis stati on 4 NE NE NE NE
ROMANIA 8161 1.27 1.19 1.36 High
76
1 Cepoi V, Onofriescu M, Segall L, Covic A: The prevalence of chronic kidney disease in the general populati on in Romania: a study on 60,000 persons. Int Urol Nephrol (2012) 44:213-220.
2 Cepoi V, Covic A, Volovăţ C: Clinical epidemiologic assessment of the incidence of chronic kidney diseases registered in Romania, Iaşi County, in the years of 2004-2008. Rev Med Chir Soc Med Nat Iasi (2009) 113:1070-6.
3 Covic A, Schiller A, Constanti nescu O, Bredeţean V, Mihăescu A, Olariu N, Seica A, Cepoi V, Gusbeth-Tatomir P: Stage 3-5 chronic kidney disease - what is the real prevalence in Romania? Rev Med Chir Soc Med Nat Iasi (2008) 112:922-31.
4*** KDIGO 2012 Clinical Practi ce Guideline for the Evaluati on and Management of Chronic Kidney Disease. Kidney int (2013) Suppl. 3:1-150. 5 Mircescu G, Stefan G, Gârneaţă L, Miti ti uc I, Siriopol D, Covic A: Outcomes of dialyti c modaliti es in a large incident registry cohort from Eastern Europe: the Romanian
Renal Registry. Int Urol Nephrol (2014) 46:443-51. 6 U.S. Renal Data System, USRDS 2013 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, Nati onal Insti tutes of Health, Nati onal Insti tute of Diabetes and Digesti ve and Kidney Diseases, Bethesda, MD, 2014. Datele au fost furnizate de Statele Unite ale Americii Renal Data System (USRDS). Interpretarea şi modul de raportare a acestora sunt responsabilitatea autorilor şi nu trebuie privite drept politi că ofi cială sau interpretare a Guvernului SUA.
7 ERA-EDTA Registry: ERA-EDTA Registry Annual Report 2012. Academic Medical Center, Department of Medical Informati cs, Amsterdam, Olanda. 8 Noordzij M, Kramer A, Abad Diez JM et al: ERA-EDTA Registry: Renal replacement therapy in Europe: a summary of the 2011 ERA–EDTA Registry Annual Report. Clin
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