CKD and RENAL REPLACEMENT THERAPY IN ROMANIA
2013
1
THE ROMANIAN RENAL REGISTRY
Ministry of Health
“Dr Carol Davila” Clinical Nephrology Hospital
Calea Griviţei nr 4, sector 1
010731 Bucharest
Romania
Phone:
+40 21 3129226
Fax:
+40 21 3129226
E-mail:
cdavilla@rdsnet.ro
Website: under construction
Personnel of the Romanian Renal Registry
Prof Dr Gabriel Mircescu
Dr Liliana Gârneață
Technicians: Eugen Podgoreanu, Viorica Ion, Daniela Isar
©Registrul Renal Român
Reference suggestions: Annual Report of The Romanian Renal Registry 2012. Ministry of Health - Clinical Nephrology Hospital
“Dr. Carol Davila” Bucharest, Romania, 2013
2
Contents
List of figures ............................................................................................. 4
Territorial distribution of the use of renal replacement therapy methods ... 29
List of tables .............................................................................................. 8
The treatment for the replacement of renal functions in children ......... 32
List of appendices ...................................................................................... 9
Survival of the patients............................................................................ 33
Data source ............................................................................................. 12
Standardized mortality ratio.................................................................... 33
Chronic kidney disease ........................................................................... 13
Survival rates ........................................................................................... 35
Data source ............................................................................................. 13
International comparisons ...................................................................... 36
Definitions ............................................................................................... 13
Incident patients...................................................................................... 36
eGFR categories ....................................................................................... 13
Prevalent patients ................................................................................... 39
Proteinuria categories ............................................................................. 14
Replacement therapy method................................................................. 39
Chronic kidney disease ............................................................................ 14
Survival of the renal replacement therapy patients ................................ 42
Stratification by risk ................................................................................. 15
Dialysis service providers ........................................................................ 43
Comorbidities in CKD............................................................................... 16
Organization and financing...................................................................... 46
Patients starting renal replacement therapy (incident patients)............. 17
Privatization and the public sector .......................................................... 46
Patients under treatment (prevalent) ..................................................... 19
The ratio between the methods .............................................................. 47
Dialysis patients ....................................................................................... 20
Treatment quality .................................................................................... 48
Hemodialysis patients ............................................................................. 23
Prices of the dialysis services .................................................................. 49
Peritoneal dialysis patients ...................................................................... 24
Conclusions ............................................................................................. 50
Patients treated by other dialysis methods ............................................. 26
Appendices .............................................................................................. 52
Transplant patients .................................................................................. 27
Bibliography............................................................................................. 76
3
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
4
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
5
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
6
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
7
List of tables
Table I. Prevalence of CKD within the adult population of Romania
14
Table II. Estimation regarding the prevalence of CKD risk groups within the adult population of Romania
15
Table III. Comorbidities requiring hospital admittance
16
Table IV. Characteristics of the incident patients of the 1st day of dialysis within the period 2007-2013
17
TableV. Characteristics of non-preemeptive transplant patients in 2013
17
Table VI. The first 15 centers by the number of newly included hemodialysis patients
18
Table VII. The first 15 centers by the number of newly included peritoneal dialysis patients
18
Table VIII. Ways of prescribing renal replacement therapy methods in the counties 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 patients 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 patients in Europe and Romania
42
Table XIII. Dialysis centers, prevalent patients by provider in Romania (2012/2011)
43
Table XIV. Weighted influences on the expenses of the Program for dialysis renal replacement
49
Table XV. The characteristics of the patients investigated for the survival analysis
53
8
List of appendices
Appendix 1. The method for the calculation of the standardized mortality ratio .......................................................................................................................... 52
Appendix 2. The method for the calculation of the survival rates .................................................................................................................................................. 53
Appendix 3. Dialysis centers, machines and patients treated on a machine in the counties of Romania in 2012, 2013 and variance 2013/2012
(in percentage) ................................................................................................................................................................................................................................. 54
Appendix 4. Dialysis patients registered on 31.12.2012 and 31.12.2013 in the counties of Romania and the variance 2013/2012 (in percentage) ................. 56
Appendix 5. Patients newly-included in the haemodialysis (HD), peritoneal dialysis (PD), non-preemptive renal transplantation (RT) and
the number of deaths in 2013 in the counties of Romania ............................................................................................................................................................ 58
Appendix 6. Prevalent patients in the dialysis centers in Romania on 31.12.2011 vs. 31.12.2010 and the variance 2012/2011 in percentage
(in the alphabetical order of the counties)...................................................................................................................................................................................... 60
Appendix 7. Prevalent and incident dialysis patients, non-preemptive transplanted or deceased patients in dialysis centers in Romania in 2013
(in the alphabetical order of the counties)...................................................................................................................................................................................... 66
Appendix 8. Haemodialysis centers ordered increasingly by the standardized mortality ratio (SMR) .......................................................................................... 71
9
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 Tetic
14.
Aurel Bizo
15.
Anca Blaga
16.
Ioan Boca
17.
Eniko Bodurian
18.
Gheorghe Boţan
19.
Lavinia Brătescu
20.
Constantin 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.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
Constantin Cruceru
Luminiţa Damian
Dionisie Dubinciuc
Sergiu Dumitrache
Hortensia Viorica Epure
Lidia Florescu
Gabriela Maria Fociuc
Nicoleta Irina Fofică
Valentina Georgescu
Ivona Georgescu
Adrian Ghenu
Mirela Gherman Căprioară
Mirela Liana Gliga
Ovidiu Golea
Sabina Grigorescu
Monica Simona Heţeganu
Mariana Iacob
Ioana Iacob
Ion Iancu
Rodica Ilieş
Ligia Iosub
Zsofia Rozalia Ivacson
Christian Klein
Raluca Ungureanu Lie
Doriana Lucaciu
Radu Macavei
Florin Mărgineanu
Simona Marian
Adriana Marinescu
Ioana Diana Mariş
Beatrice Marusceac
Sorina Masek
Marilena Micu
Ileana Mihăilescu
69.
70.
71.
72.
73.
74.
75.
76.
77.
78.
79.
80.
81.
82.
83.
84.
85.
86.
87.
88.
89.
90.
91.
92.
93.
94.
95.
96.
97.
98.
99.
100.
101.
102.
Eugen Moţa
Dan Munteanu
Mihaela Munteanu
Ioana Nicoleta Nicolae
Marcel Palamar
Radu Viorel Pâtea
Ioan Mihai Paţiu
Marilena Piper
Mariana Pop
Luminiţa Popa
Marcela Pravăţ
Daniela Pricop
Monica Radu
Mihai Raicu
Eugenia Răilean
Violeta Roman
Leonard Roşu
Mihaela Roşu
Cornel Rusan
Oana Schiller
Cristian Serafinceanu
Aurelian Simionescu
Petronela Şodolescu
Costel Spânu
Roxana Dorina Stavăr
Ioana Suciu
Dorina Tacu
Cătălin Tacu
Mircea Ţandrău
Cristina Teodoru
Delia Timofte
Daniela Elena Tir
Camelia Totolici
Carmen Turcea
103.
104.
105.
106.
107.
108.
109.
110.
111.
112.
113.
114.
115.
116.
117.
118.
119.
120.
121.
122.
123.
124.
125.
126.
127.
Liliana Tuţă
Cristina Văduva
Peter Varga
Mariana Vasilescu
Adina Monica Vereş
Gabriela Voicu
Mihai Voiculescu
Carmen Volovăţ
Diana Zilişteanu
Adrian Zugravu
Radu Drăgulete
Adriana Buhai
Tatiana Șuiaga
Mirela Modâlcă
Cristiana David
Elena Bălțatu
Claudia Cusai
Ana Maria Dominte
Suzana Anca Berca
Diana Copăceanu
Andreea Costea
Mihaela Iavorenciuc
Carmen Denise Căldăraru
Adrian-Bogdan Ghigolea
Oana Sklerniacof
10
Persons in charge with the relationship with RRR
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
Cati Aursăchioaie
Gaspar Balazs
Zoltan Barabas
Mariana Becheanu
Mirela Beldean
Mihaela Beldiman
Marcela Berar
Mariana Bîrsan
Istvan Blenyesi
Georgeta Blidariu
Ilie Blotor
Marian Boboc
Maria Boeru
Cristiana Bojica
Adrian Bosie
Marin Brașoveanu
Ioana Breaza
Ana Maria Igna
Cristina Bursuc
Narcis Buturugă
Otilia Carteleanu
Nicoleta Stoica
Veronica Călin
Cipriana Cherecheș
Beniamin Chifor
Ionela Chirigiu
Teodora Condriuc
Romulus Corban
Lucian Costăchescu
Valerica Crîșmaru
Georgiana Cutocheraș
Loredana Danciu
George Dănăilă
Stela Dănulescu
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
Doru Deju
Adrian Dobrițoiu
Olga Dragula
Gina Dumbravă
Elena Durubală
Camelia Epure
Mirela Faur
Livia Flore
Emilian Floroaia
Margareta Grădilă
Gabriela Ioniță
Delia Iordache
Elena Lazăr
Elena Lulciuc
Sergiu Lupulescu
Anca Maczo
Gabriela Maftei
Aurel Marian
Elena Marin
Sorina Matei
Amalia Mihance
Paula Mîndreanu
Elena Munteanu
Sanda Nica
Luminiţa Nițu
Mirela Olaru
Monica Olăroiu
Răducu Olteanu
Claudiu Oțetea
Elena Pais
Ionela Palade
Ionela Pascal
Irina Pert
68.
69.
70.
71.
72.
73.
74.
75.
76.
77.
78.
79.
80.
81.
82.
83.
84.
85.
86.
87.
88.
89.
90.
91.
92.
93.
94.
95.
96.
97.
98.
99.
100.
Monica Crăciun
Florentina Petrescu
Oana Petruț
Tania Câmpeanu
Adriana Ploscar
Veronica Ploștenaru
Dana Poborena
Marius Popoacă
Melania Prioteasa
Anca Pucerea
Maricica Radu
Carmen Raicu
Liliana Răcoreanu
Monica Rodina
Mădălina Rugină
Anca Rusu
Angelica Sandu
Maria Savu
Ioan Schink
Florentina Sebacher
Bianca Semeniuc
Dorina Serciu
Roxana Seserman
Laura Slabinschi
Ştefania Stănescu
Doina Stângă
Monica Stoica
Elena Stoina
Zoe Stroe
Cristian Stupinean
Monica Suciu
Liliana Şerban
Armand Ştefănescu
101.
102.
103.
104.
105.
106.
107.
108.
109.
110.
111.
112.
113.
114.
115.
116.
117.
118.
119.
120.
121.
122.
123.
124.
125.
126.
127.
128.
129.
130.
131.
Angela Ştirbu
Mădălina Tene
Ioana Tipa
Cristina Toacă
Carmen Tonița
Erika Trif
Lenuţa Tucă
Daniela Tudor
Lucian Tudora
Georgeta Turc
Constantin Vlădescu
Elena Voiculescu
Francisc Zabos
Mihaela Zaraza
Georgeta Cristina Niță
Eugenia Naftan
Cristina Tutuianu
Elena Ilie
Emilia Chifor
Alina Bâlcă
Cristina Zamora
Nicoleta Huzum
Gabriela Moise
Dana Sabie
Adriana Cerăceaun
Elena Anastasiu
Daniela Duță
Diana Mocanu
Violeta Gabor
Camelia Șendroiu
Andreea Boțan
11
Data source
REPORT ON THE RENAL REPLACEMENT
THERAPY IN ROMANIA 2013
The report regarding the situation 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 participation of 97% of the existing dialysis centers in 2013.
The data regarding the kidney transplantation in incident dialysis patients are received from the dialysis centers, while the data regarding the pre-emptive
kidney transplantation and the monitoring of the prevalent kidney transplant patients are provided by a single transplantation center from the four existing
centers. The number of prevalent transplant patients on 31.12.2012 and 2013 was provided by the National Health Insurance House.
Epidemiology of Chronic kidney disease was evaluated using data collected in the Romanian Ministry of Health Program of Health Status Evalution in a cohort
from Iassy county. The new analyses complete the already published data1,2,3.
12
Chronic kidney disease
Data source
The database created during the Program of Health
Status evaluation (2007-2008) in the Iași county
contained information on 176,586 subjects. Data on
serum creatinine and the proteinuria were available
for 32,174 subjects. After excluding participants with
age below 21 years, the final population analyzed
included 30,068 adults (17% of the evaluated subjects,
4% of the county population).
De�initions
CKD diagnosis, eGFR and proteinuria categories and
the stratification by risk were defined according to
KDIGO 20124 (Figure 1). Because proteinuria was
qualitatively measured using strips or quantitatively,
the results were converted in A1-A3 risk categories
as described by KDIGO, and the eGFR was estimated
based on serum creatinine level and CKD-EPI formula.
>90mL/min
89-60mL/min
45-59/mL/min
44-30mL/min
29-15mL/min
<15mL/min
G1
G2
G3a
eGFR categories
G3b
G4
G5
Risk
Minimum
Low
Moderate
High
A1
<30mg/day
Absent
Proteinuria categories
A2
30 – 300mg/day
1+
A3
>300mg/day
>1+
Figure 1. Stratification of CKD partients by renal and cardio-vascular risk according to eGFR
and proteinuria categories
70%
6 0%
50%
eGFR categories
4 0%
The prevalence of G3-G5 CKD stages was lower in
the NHANES cohort than in the adult population of
Romania. The prevalence of persons in G1 was lower,
but higher in G2 and G3a categories, in Romania as
compared to USA. These differences are probably due
to the higher prevalence of diabetes in the USA and
to a selection bias in the Iași cohort, where seems
that especially patients with comorbidities came for
evaluation (Figure 2).
30%
57.9 %
4 5.3%
4 5.1%
35.4 %
NHANES
Ro
20%
10%
0%
4 .6 %
G1
G2
7.7%
G3a
6 .7%
1.6 % 1.6 % 0.4 %
G3b
0.2%
G4
9 .7%
0.1% 0.1%
G5
G3-G5
Figure 2. The distribution within the eGFR categories (G1-G5) of the Romanian
and the NHANES cohort
13
Proteinuria categories
100%
The distribution within the proteinuria categories was almost
numerical equal in NHANES and Romanian cohorts (Figure 3).
9 3, 2%
80%
6 0%
Chronic kidney disease
NHANES
Ro
4 0%
CKD (defined 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).
20%
5, 4 %
0%
By extrapolation to the entire adult population of Romania,
about 1,900,000 persons are affected by Chronic kidney
disease, from which 275,000 would require specialized
nephrology care (stages 3b-5). (Table I).
A1
4 , 0%
1, 1%
1, 3%
A2
A3
Figure 4. The distribution within the proteinuria categories in
the Romanian and NHANES cohorts
Table I. CKD prevalence CKD in the adult population of Romania
CKD category
Percentage
Number
G1 + A2-A3
0.7%
101.200
G2 + A2-A3
2.8%
404.801
G3a
7.7%
1,113,202
G3b
1.6%
231.315
G4
0.2%
28.914
G5
0.1%
14.457
Total CKD
13.1%
1,893,889
On May 31st 2014 the population of Romania was
of 19,631,292, and the population above 24 years
of age reached to 14,457,168 inhabitants (INS)
9 4 ,9 %
14 %
11, 5%
12%
13, 1%
10%
7, 7%
8%
6 %
4 %
2%
0%
NHANES
4 ,6 %
2, 5%
2, 3%
0, 7%
RO
2, 8%
1, 6 %
1, 6 %
0, 4 %
0, 2%
0, 1%
0, 1%
Figure 3. The distribution of the CKD categories within the Romanian and NHANES cohorts
14
NHANES
NHANES
57.9
57.9
34.5
34.5
3.6
G1
Strati�ication by risk
Although the distribution by eGFR and albuminuria
categories differed, there were no major differences
in the distribution of the two cohorts in the risk groups
(Figure 3).
3.6
G1 G2
1.0
G2 G3a
1.0
G3a G3b
G3b G4
G4
0.2
0.2
G5
0.1
0.1
G5
A1
A1
Table II. The estimated prevalence of CKD risk groups within
the Romanian adult population
CKD category
Percentage
Number
Minimum risk
86.9%
12,468,609
Low risk
9.2%
1,316,303
Medium risk
3.0%
437,177
High risk
0.9%
128,385
On May 31st 2014 the population of Romania was of
19,631,292, and the population 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 existing 300
nephrologists.
15%
15%
10%
A2
A2
A3
A3
România
România
45.1%
45.1% 45.3%
45.3%
10%
5%
6.5%
5%
0%
G1
0%
G1 G2
G2 G3a
G3a G3b
G3b
6.5%
1.3%
1.3%
G4
G4
0.2%
0.2% 0.1%
G5
G5
0.1%
A1
A1
A2
A2
A3
A3
Figure 5. The distribution of risk groups in the Romanian and NHANES cohorts
15
Comorbidities and CKD
The main comorbidities 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
influenced by the CKD, even though the average number
of admissions was lower in CKD (Table III).
Figure 6. The prevalence of the main comorbidities requiring hospital
admittance (CKD – Chronic kidney disease, DM – diabetes mellitus)
Table III. Comorbidities imposing hospital admission
CKD
Non-CKD
6.4
10.5
• 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
Hospital admissions
(for 100 persons-years)
Comorbidity (% admittances)
According to causes of admission, the estimated
prevalence of diabetes mellitus, cardiovascular diseases,
and CKD were 9%, 30% and 10%, respecttively. All these
pathology categories were strongly related (Figure 6).
•
The Chronic kidney disease has a higher prevalence in Romania that in the
NHANES cohort: 13.1% vs. 11.5%; the estimated number of adult persons
with CKD in Romania is about 1,900,000.
•
Since the number of CKD patients with medium-high risk is 565,000, a
nephrologist should have under care 1,900 patients
(approximately 20 visits/day).
•
CKD patients suffer more often from diabetes mellitus, HBP, stroke and heart
failure, and their risk of death is twice higher. As a result, the CKD care should
be multidisciplinary (diabetology, cardiology and nephrology).
•
The medical assistance is mainly provided in hospital (over a quarter of the
pa-tients are admitted into hospital), regardless of the state of the kidney,
and the CKD patients have almost twice as many hospital admittances.
•
Thus, multidisciplinary CKD medical care programs promoting ambulatory
care are needed.
16
Table IV. Characteristics of incident patients in the 1st day of dialysis within the period 2007-2013
2007
2008
2009
2010
2011
2012
2013
75
85
102
131
148*
137*
138*
100
100
98
90
92
96
97
Number
1,910
2,036
2,377
2,662
2,987
3,428
3,063
Sex (B%)
58.8
57.8
57.7
57.5
57.6
57.8
56.7
Average age (years)
58.1
58,.3
60.5
61.2
62.0
62.6
62.6
34
37
39
39
41
43
42
Glomerulonephritis (%)
17.1
16.2
13.5
13.9
13.6
13.7
12.6
Interstitial nephritis (%)
12.4
11.5
11.4
11.2
11.3
11.3
10.0
Hereditary-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
14.7
6.5
11.8
6.2
6.3
14.5
15.4
9.9
Other (%)
15.5
9.4
6.4
7.4
5.5
6.4
10.7
Unknown (%)
31.1
25.4
38.7
43.3
35.0
30.9
37.7
Centers (number)
Reporting centers (%)
Incident RRT patients
Dialysis incident patients were mainly men, with
a mean age of 62.6 years (42% above 65 years).
The most frequent primary kidney disease was
diabetic nephropathy (14.7%), but in more than
a third of patients (37.7%) the primary renal
disease was not known. This high proportion
of undiagnosed cases highlights the late CKD
identification imposing emergency dialysis
initiation (Table IV).
Non-preemptive transplanted patients are mostly
men and are younger than incident dialysis
patients. The most frequent primary kidney
disease was glomerulonephritis (45.9%) and
was unknown in more than a third of the cases
(36.2%) (Table V).
Incident patients day 1
≥ 65 years (%)
Primary kidney disease
Kidney vascular disease (%)
Replacement therapy method at the beginning
HD (%)
82.3
82.0
83.6
93.5
93.8
95.1
95.0
DP (%)
17.7
18.0
16.4
6.5
6.2
4.9
5.0
Table V. Characteristics of incident non-preemeptive transplant patients in 2013
• The incident patients’ characteristics are
changing: the proportion of the diabetic
patients above 65 years is increasing (42%
and 15%), which would imply additional
resources for care.
• As there are no efficient programs addressing
CKD before the renal replacement therapy
initiation, the dialysis is initiated under
emergency condition with higher morbidity
and mortality rates and higher costs, and
primary renal disease is barely diagnosed.
Sex (B%)
67.9
Age
average (years)
42.1
≥ 65 years (%)
1.4
Primary kidney disease
Glomerular nephritis (%)
45.9
Interstitial nephritis (%)
2.8
Hereditary-congenital (%)
5.1
Diabetes (%)
2.2
Renal vascular diseases (%)
2.8
Other (%)
5.0
Unknown (%)
36.2
17
Table VI. The first 15 centers by the number of newly
included hemodialysis patients
Center
“Dr. C. I. Parhon” Clinical Hospital Iasi
Most of incident patients 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” Institute and “Sf
Apostol Andrei” Galați, for peritoneal dialysis)
(Tabelul VI, Tabelul VII).
Newlyincluded
patients
261
Table VII. The first 15 centers by the number of newly
included peritoneal dialysis patients
Center
“Dr. Carol Davila” Clinical Nephrology
Hospital – Bucharest
“Fundeni” Clinical Institute
Newlyincluded
patients
16
“Dr. Carol Davila” Clinical Nephrology Hospital – Bucharest
University Emergency Hospital Bucharest
172
133
“Sf. Ap. Andrei” County Hospital - Galati
12
“Sf. Ioan cel Nou” County Hospital Suceava
132
IHS - Buzau
10
“Sf. Ioan” Clinical Hospital Bucharest
110
Bacau County Hospital
10
Craiova County Emergency Hospital
103
14
Braila County Hospital
8
Constanta County Emergency Hospital
92
Craiova County Hospital
5
Cluj County Hospital
76
Renamed Nefrodial - Oradea
5
Arad County Hospital
74
“N. Paulescu” Institute Bucharest
5
Prahova County Hospital
67
Fresenius NephroCare - „CI Parhon” Iasi
5
Sibiu County Hospital
67
IHS “Sf. Ioan” Bucharest
4
Timis County Hospital
62
IHS - Ramnicu Valcea
4
Brasov County Emergency Hospital
61
University Emergency Hospital Bucharest
3
Dambovita County Hospital Targoviste
61
Teleorman County Hospital – Alexandria
3
Hunedoara County - Deva
56
“Sf. Pantelimon” County Hospital - Focsani
3
Total
1.527*
* 58% of total number of newly included patients
Total
107*
*69% of total number of newly included patients
18
12, 000
+ 8%
10, 322
9 , 551
10, 000
8, 000
2012
6 , 000
4 , 000
The total number of patients 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 patients (+8%), while
peritoneal dialysis decreased by 7% (Figure 7).
The number of RRT patients per million inhabitants
reached to 732, increasing, but still below the
European average from 2012 (947 RRT patients 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 patient number it is expected to
decrease.
• Renal replacement therapy coverage in
Romania approaches the European average
that it shall reach in 2016.
2, 4 57 2, 723
- 7%
2, 000
9 19
-
HD
854
DP
RTx
Figure 7. Number of patients treated by hemodialysis (HD), peritoneal dialysis
(PD) and renal transplantation (RTx) in 2012 and 2013 in Romania
14 00
RRT patients per million population
Patients under treatment (prevalent)
2013
+ 11%
119 6
1200
1000
800
889
6 80
9 4 0
9 9 1
104 2
109 4
ED TA- ERA 2012
732
6 00
4 00
200
0
2012
2013
2014
2015
2016
2017
2018
2020
Figure 8. Estimated number of RRT patients in Romania (per million inhabitants)
19
11.176
Preevalent dialysis patients (number)
12, 000
10, 000
8.371
8, 000
6 , 000
3.06 4
4 , 000
2, 000
1.203 1.59 1
1, 16 4
0 39
19 9 5
1, 4 86
105
19 9 6
2.19 5
1, 9 6 0
235
19 9 7
3.56 5
2.715
4 .272
3, 502
4 .9 74
4 , 09 8
5.800
6 .034
8.4 24
9 .09 7
9 .755
10.4 70
6 .9 86
6 .283 6 .715
4 , 700
4 , 9 86
5, 138
5, 4 6 0
5, 587
6 , 9 86
7, 255
8, 06 8
8, 74 8
9 , 551
2, 39 1
2, 6 4 8
3, 04 9
324
19 9 8
4 16
516
770
876
1100
104 8
114 5
1255
139 9
1385
116 9
1029
1007
9 19
19 9 9
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
DP
HD
10, 322
854
2013
Total
Figura 9. Prevalent dialysis patients in Romania (numbers, 1995-2013)
Dialysis patients
However, the rate of increase decreased to 6.7% in 2013,
below the average of the last 5 years (Figure 10).
d e a n u l a n te ri o r
The rate of increase was not constant: the initial fast increase
(1996-2000; +32.7%/year) slowed down (2001-2003 and
2004-2006), and finally the rate increased again to 7.3%/year
in 2007-2013 (Figure 9).
P r o c e n te fa
Since 1996 the total number of patients prevalent on dialysis
constantly increased, exceeding 11,000 in 2013 (Figure 9).
9
8, 0%
8
7
7, 2%
7, 3%
6 , 7%
6 ,4 %
6
5
4
3
2009
2010
2011
2012
2013
Figure 10. The rate of increase in prevalent dialysis
patients in Romania (2009-2012; in percentage as
compared to the previous year)
20
•
Prevalence of Chronic kidney disease;
Resources allocated for dialysis, i.e. number of
dialysis facilities and reimbursement by Health
Insurance House;
Efficiency of the transplantation program.
Since there are no reasons to believe that CKD
prevalence differs in Romania from Europe, the
prevalence of dialysis patients should be similar.
Therefore, the number of dialysis patients shall
increase gradually in Romania until it reaches the
European average. In 2013 there were 666 dialysis
patients per million inhabitants (pmi) in Romania,
compared to the European average of 883, which
corresponds to a total number of dialysis patients
of 17,660 in Romania (Figure 11). Thus, the number
of Romanian dialysis patients shall continue to grow
by more than 5% each year until it reaches 18,000,
depending on the Health Insurance House funding.
The lower than 7% rate of increase in prevalent
patients observed in 2013 is probably due both to
the progressive coverage of the dialysis need of
the population and to the more active transplant
program. As the number of prevalent patients (an
indicator of the dialysis coverage) increases, the
rate of increase in the number of patients has a
decreasing trend (Figure 12).
883
800
6 00
4 00
353
318
331
2004
2005 2006
4 20
4 9 8
507
582
54 7
59 2
6 6 6
200
0
2007 2008 2009
2010 2011 2012 2013 EDTA
( 2010)
Figure 11. Dialysis patients in Romania (2004-2013) and in Europe (2010)
(per million inhabitants - pmi)
15000
9
8.5
8.0
12500
7.2
10000
7.3
11, 176
9 , 755
7.1
6 .5
84 24
2009
2010
2011
7
7.1
6 .7
9 , 087
7500
7.5
11, 84 8
10, 4 70
6 .4
8
12, 537
2012
Number of prevalent patients
Rate of increase ( %)
•
•
Number of prevalent patients
The number of dialysis patients depends on the:
Prevalent dialysis patients (pmi)
1000
2013
2014
2015
6
Rate of increase (%)
Figure 12. Estimated trends in prevalent patients number and in the rate of increase
(percent of the previous year) in Romania 2009-2015
21
15, 000
4 19
10, 000
8, 371
4 21
4 55
9 , 09 7
8, 4 24
524
4 88
9 , 755
10, 4 70
559
11, 176
582
11, 6 31
12, 226
2, 017
0
2008
2009
2, 4 88
2010
2, 4 9 8
2011
12, 821
701
6 71
13, 4 16
14 , 010
14 , 6 05
76 0
15, 200
800
6 00
4 00
5, 000
2, 24 8
6 4 1
6 11
730
2, 86 4
2, 79 9
2012
2013
Prevalent patients (number)
3, 06 2
2014
3, 39 5
2015
Incident patients
3, 589
2016
3, 6 14
3, 557
2017
2018
4 , 051
3, 886
2019
2020
200
Incident dialysis patients (number)
Prevalent dialysis patients (number)
20, 000
0
Prevalent patients (pmpi)
Figure 13. Estimated prevalence and incidence of dialysis patients in Romania (pmi - per million inhabitants)
The model in Figure 14 suggests that, if the current trends are maintained:
• The estimated rate of increase in prevalent patients number for 2014-2015 is 7%;
• In 2014, 11,600 patients will be treated by dialysis, and in 2015, 12,200.
• In 2014, 3,100 new patients will be included in dialysis, and in 2015, 3,400.
22
Hemodialysis patients
The number of incident hemodialysis patients
doubled from 2007 to 2013. The prediction for
2014 and 2015 is of 3,400 and 3,600 incident
hemodialysis patients (Figure 14).
If the current trends are maintained:
• by the end of 2014 there will be 11,000
patients treated by hemodialysis, and by the
end of 2015, 11.800.
• In 2014 and 2015 there will be 3,400 and
respectively 3,600 incident hemodialysis
patients.
16 .00
Prev alent HD p atients ( thousands)
The number of prevalent hemodialysis patients
steadily increased, faster within the last 5 years.
If the current trends are maintained, by the
end of 2014 11,000 patients shall be treated by
hemodialysis, and by the end of 2015, 11.800
(Figure 14).
12.00
8.00
6 .9 9
7.26
8.07
8.75
9 .55
10.32
11.05
11.79
12.54
13.20
14 .01
14 .75
15.4 9
5.59
4 .00
1.9 1
0.00
2.04
2.38
2007 2008 2009
2.6 6
2.9 8
3.4 4
2.6 4
3.38
2010 2011 2012 2013 2014
3.58
3.78
2015 2016
3.9 6
4 .11
4 .26
2017 2018 2019
4 .4 2
2020
Figure 14. Estimated number of incident and prevalent hemodialysis (HD) patients in Romania
23
Peritoneal dialysis patients
14 00
Prevalent PD patients (number)
Peritoneal dialysis has a series of advantages, both
medical (low patient dependence on the dialysis
center, better preservation of renal function than
hemodialysis) and economic (lower therapy cost,
which would allow to treat more patients with the
same budget). Although peritoneal dialysis has few
medical contraindications, the proportion of PD
patients is decreasing in Romania and worldwide. If
the current trend is maintained, peritoneal dialysis
shall practically disappear in Romania by the year
2020 (Figure 15).
16 00
R² = 0.9 7
139 9 1385
1255
116 9
1200
1029 1007
1000
9 19
854
800
780
6 52
6 00
56 2
503
4 25
330
4 00
24 3
200
Although the causes of the decrease in peritoneal
dialysis usage are less understood, three factors
seem relevant:
• Deficient predialysis CKD care, imposing
emergency initiation of RRT, not allowing the
patient to choose in full awareness the most
suitable therapy;
• The costs for the initiation of peritoneal dialysis
therapy are not deducted to the hospitals by the
National Health Insurance House;
• The price difference, which is detrimental to
peritoneal dialysis and makes it less attractive
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 noticed in Romania (Figure 16)
0
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Figure 15. Estimation of prevalent peritoneal dialysis (PD) patients’ number in Romania
100%
9 5%
87%
80%
6 0%
4 0%
30%
16 %
20%
20%
0%
2007
17%
14 %
11%
2008
2009
2010
Patients treated by private providers ( % )
12%
12%
11%
10%
2011
9 %
2012
8%
2013
PD patients ( % )
Figure 16. The proportions of patients treated by peritoneal dialysis (PD)
and of those treated by private dialysis providers in Romania
24
4 , 000
On the other hand, the costs of peritoneal dialysis
were more affected by the recent increase of the VAT
tax, of the currency exchange rate and by the changes
in the medicine price calculation, not mentioning
the more costly newly introduced peritoneal
dialysis solutions than the costs of hemodialysis
(24% vs. 13%). Accordingly, as peritoneal dialysis is
economically less attractive then hemodialysis for
private providers, its usage will be restrained.
3, 500
Incident p atients ( number)
Although CKD evolution is predictable, which
would allow preparing the patients in time for
RRT initiation, including appropriate education,
in Romania there are no programs addressing
predialysis CKD care. That is why renal replacement
therapy is frequently initiated in an unplanned
manner, and the patients have not the possibility to
choose in full awareness their best suited method
of therapy. Accordingly, developing programs of
predialysis CKD care with an educational component
would also allow reversing the descending trend in
peritoneal dialysis usage.
R² = 0.89 15R² = 0.84 4 3
3, 000
2, 4 88
2, 500
2, 000
1, 500
1, 572
3, 380
3, 26 9
2, 801
3, 6 38
2, 6 4 4
1, 9 88
1, 6 6 9
1, 000
500
0
338
2007
36 7
2008
39 0
2009
183
174
2010
HD
2011
174
2012
155
2013
9 1
2014
34
2015
DP
Figure 17. Trends in dialysis methods usage in Romania
(incident patients; 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 patients treated by PD,
and 100-150 patients shall be included in the treatment in the years 2014
and 2015 (Figure 18).
25
Patients treated by other dialysis
methods
Hemodiafiltration (HDF) and automated peritoneal
dialysis (APD) are conditionally accepted by the NHIH
for reimbursement up to 7-10% of prevalent patients,
due to their higher costs than those of the conventional
therapy. Their use was not widespread, as they are
prescribed to 6.4% and 1.4% of the HD and DP prevalent
patients, respectively (Figure 18).
However, by changing the eligibility criteria for
patients accepted by NHIH, i.e., young patients with
no transplantation perspective for HDF, and raising
the limit for APD to allow young patients having a high
transplantation probability to be treated, would allow a
better allocation of the resources.
• Hemodiafiltration and automated peritoneal
dialysis treatments are prescribed within the
limits accepted by NHIH.
• Changing the eligibility criteria for these
treatments would allow a better allocation of
the resources.
100%
DPA 1,0%
DPA 1,4%
9 5%
DPCA
7,8%
DPCA
6,2%
HDF
4,0%
HDF
6,2%
9 0%
DPCA
HDF
85%
80%
DPA
HD
HD
87,2%
HD
86,1%
2012
2013
75%
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 – hemodiafiltration; HD- hemodialysis)
26
Transplant patients
Most of the grafts came from deceased donors
(56%), showing an increase compared to 2012
(Figure 20).
R² = 0.7781
10.0%
3, 158
8.0%
6 .0%
1, 9 33
2, 4 21
2, 073
3, 700
3, 59 1
6 .2%
5.5%
7.0%
0.0%
3, 000
2, 000
1, 500
4 .0%
2.0%
4 , 000
2, 500
7.2%
4 .1%
4 , 500
3, 500
3, 017
2, 6 81
3, 9 4 6
1.2%
2007
1.8%
1.8%
1, 000
0.7%
2008
2009
2010
500
2011
2012
Incident RRT patients
2013
2014
2015
Incident RRT patients (number)
However, data are not accurate enough, since
they are based on dialysis centers reports and
include only non-preemptive transplants, as a
functional transplant registry does not exist in
Romania. Moreover, as there are no follow-up data
in transplanted patients, the real contribution of
transplant to the renal replacement therapy can
hardly be assessed.
12.0%
Non-preemptive transplants
(%)
As compared to dialysis, renal transplantation has
medical and economic advantages, but is less used
in Romania. Although the number of grafts has
continuously increased within the last 3 years, only
7% of incident RRT patients were non-preemptively
transplanted in 2013 (Figure 19).
0
Non-preemptive transplants
Figure 19. Incident patients on day 1 in renal replacement therapy in the period 2007-2015 and the
percentage of non-preemptive transplant patients)
100%
• The number of renal transplants increased, the
grafts from deceased donors are predominant,
but transplantation still contributes to a lower
proportion to RRT (7% of the incident patients).
• Although 230 and 275 non-preemptive transplants are estimated for 2014 and 2015, at least
400 should be financed to help transplantation
effectively contribute to RRT in Romania.
• In order to obtain accurate data on transplanted
patients, mandatory reporting of the transplant
patients to the Romanian Renal Registry should
be introduced.
16
18.8
75%
Donor of uknow n type
Cadaveric donor
50%
53
56
U nrelated living donor
Related living donor
25%
0%
1
2.7
28
22.5
2012
2013
Figure 20. Origin of kidney grafts for non-preemptive transplantation in 2013 and 2014
27
NHIH records included 2,723 prevalent transplant
patients, an 11% increase as compared to 2012.
Thus, renal transplantation recorded the highest
increase among renal replacement therapy
methods in Romania, exceeding even hemodialysis
rate (Figure 21).
• Renal transplantation had the highest
increase among renal replacement therapy
methods, as judged by the number of
prevalent patients.
• It could be estimated that the number of
prevalent transplant patients will exceed
3,000 in 2014.
Prevalent patients 2012/ 2013 ( %)
12%
10%
8%
11%
8%
6 %
4 %
2%
0%
-2%
-4 %
-6 %
-8%
HD
-7%
D P
RTx
Figure 21. Rate of variation (2013/2014; %) in RRT prevalent patients number
28
2011
D ialysis p rev alent p atients ( p mi)
Territorial distribution of RRT
methods
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 exception. 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).
2013
D ialysis p rev alent p atients ( p mi)
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 counties (Figure 22, Figure 23).
The inhomogeneous coverage will perpetuate, as the
counties having the highest prevalence also have the
highest number of newly included patients, while the
counties with the lowest number of prevalent patients
reported in 2013 less inci-dent patients that the
national average (Cl, CV, CS, GL, GR, IL, OT) (Figure 23).
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 defined by
the national median and by the quartiles.
29
• There are high differences in dialysis coverage
between the counties of Romania.
• Since in counties with university centers there
are up to 3 times more dialysis patients than
the adjoining counties, a possible explanation
of the inhomogeneous distribution would
be the patients’ preference for university
centers.
• Several counties had the lowest prevalence
of the dialysis patients in consecutive years
and the lowest number of newly included
patients in the country (IL, CL, GL, GR, OT, MS,
CV). These counties seem to be the target
of the programs addressing Chronic kidney
disease.
MH
B+IF
IS
SB
BR
V N
CJ
GJ
BH
HD
V S
NT
BT
V L
BV
DJ
AB
BC
România
SV
TL
AG
CT
BZ
TM
HR
MM
SM
PH
DB
AR
SJ
BN
CV
TR
OT
IL
MS
CS
GL
CL
GR
151
14 1
132
108
19 1
19 6
9 6
57
80
4 7
0
0
205
227
137
16 6
16 5
102
88
150
210
103
14 0
9 8
116
80
9 2
113
9 4
121
176
129
133
81
134
76
6 6
38
4 1
6 3
20
100
200
750
750
738
375
720
713
6 73
6 73
6 4 7
6 4 7
6 19
6 04
59 1
582
578
574
572
570
558
555
550
54 9
527
513
505
4 9 0
4 86
4 81
4 6 8
4 6 5
4 6 1
4 4 1
4 4 1
4 4 0
4 33
4 29
4 03
39 0
372
36 2
332
330
274
26 3
300
4 00
500
6 00
700
Prevalent patients
Incident patients
800
Figure 23. Dialysis prevalent and incident patients (per 1 million inhabitants) in
Romanian counties (in descending order)
30
2013
PD incident patients (pmi)
Theoretically, the renal replacement therapy
methods should be complementary used to match
the patients’ needs. Based on incident patients’
allocation to the RRT methods, in Romania there
are four pattern of prescription: 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 counties all three
methods are prescribed, in some of them HD is used
either only in association with PD (South Moldavia,
East Muntenia), only with RT (Central Transilvania),
and in others HD is prescribed exclusively
(Table VIII, Figure 24).
2013
RTx incident patients (pmi)
Table VIII. Patterns of RRT prescription in the counties
of Romania (2013)
HD+DP+TR
HD+DP
HD+TR
HD
AG, B+IF, BH, BV, CJ, CS, CT, DJ, GL,
HD, IS, SB, SM, TM
BR, BZ, PH, OT, TR, VN
AB, AR, BN, HR, MS, NT, SJ, TL, VS
CL, GR, IL, MM, SV
• The use of renal replacement therapy
methods in Romania shows significant area
variations, reflecting the lack of an unitary
practice and can influence both the evolution
of the patients, and the costs of renal
replacement therapy.
Figure 24. The distribution of incident patients in peritoneal dialysis (PD - up) and in nonpreemptive 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
The RRT in children
In 2013, from the eight pediatric functioning
centers, five are only discontinuously functioning.
The total number of children treated by dialysis on
31.12.2013 decreased slightly, reaching to 121.
Table IX. Dialysis therapy in children in Romania (2007-2013)
2007
2008
2009
2010
2011
2012
2013
7
7
7
8
8
8
8
The number of children incident in dialysis
continued to have an increasing trend, reaching up
to 30 in 2013.
Centers (number)*
Number
103
110
119
115
117
123
121
The ratio of patients treated by peritoneal dialysis
continued to decrease down to the maximum level
of 30% reached in 2008, reaching to 6.7% in 2013
(Table IX).
Sex (B%)
53,4
51,8
52,1
53,0
52,6
52,1
52,3
Number
35
30
29
28
28
28
30
Sex (B%)
51,3
47,8
54,0
52,4
52,6
51,9
50,0
- 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
• 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
transplantation.
• There are no available data about transplantation in children.
Prevalent patients on 31.12
Incident patients day 1
Dialysis method at RRT initiation
*Five pediatric centers function intermittently
32
9 , 000
Survival of RRT patients
4 , 000
1.58
3, 886
1.36
1.5
1.30
1.07
1.27
1.00
1
3, 000
2, 000
0
Fresenius
0.5
9 34
9 56
9 4 5
74 8
6 9 2
Public
IHS
D iav erum
Av itum
Other
0
Romania
Figure 25. Standardized mortality ratio (SMR) in hemodialysis patients by provider (2012)
10, 000
3
886 5
9 , 000
Prevalent HD patients (number)
In 2012 and 2013, the mortality rate of
hemodialysis patients 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, after
being higher in 2012. Public dialysis centers
have a double mortality rate compared to
the reference level (Figure 25, Figure 26).
5, 000
1, 000
This type of analysis allows the comparison
between the mortality observed in a
population or in cohorts specifically defined,
and the national mortality rate assessed in a
reference cohort (see Appendix 1).
A SMR strictly above or below 1 describes
in percentage how higher or respectively
lower is the mortality rate versus the
national reference rate. SMRs not strictly
above or below 1 indicate mortality rates
similar cu the national reference rate.
6 , 000
SMR
Standardized mortality ratio (SMR) is
the ratio between the observed and the
expected number of deaths. SMRs are used
to compare the survival of the patients
treated in a center (county or network) to
the national mortality rate.
2
2.00
7, 000
2.5
8, 000
2.25
7, 000
2
6 , 000
5, 000
4 , 000
3, 000
1.5
4 132
1.09
2, 000
1, 000
0
Fresenius
1.09
1.26
1.19
1.23
1.05
877
1034
104 3
889
6 9 2
Public
IHS
D iav erum
Av itum
Other
SMR
Standardized mortality ratio
8, 000
Prevalent HD patients (number)
Survival is a synthetic indicator of the quality
of dialysis therapy.
2.5
8, 16 1
1
0.5
Romania
Figure 26. Standardized mortality ratio (SMR) in hemodialysis patients by provider (2013)
0
33
Unfortunately, the standardized mortality ratio cannot be used to classify
dialysis centers (Appendix 9).
• The HD patients’ 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 proportion of
incident patients does not fully account for the rise of the mortality rate.
As other comorbidities or other factors can be involved, further analyses
are needed for clarification of the observed increase in mortality.
• Public centers had twice higher SMR than the reference rate, probably
because they initiate the treatment (period with the highest death risk)
and treat the cases with the highest burden of comorbidities.
34
Survival rates
Survival
The mean survival of the RRT patients starting 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 calculation
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
patients 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
Time (months)
Figure 27. Cumulative survival rated of patients starting renal
transplantation (TR), hemodialysis (HD) or peritoneal dialysis (DD)
in 2008-2011 in Romania
Table XI. Determinants of RRT patients’ survival in Romania
Determinants
RRT vs RTx
HD (vs. RTx)
PD (vs. RTx)
• RTx patients had 5 times 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%, respectively.
HR
P
5,61
5,63
<0,001
<0,001
<0,001
Age
1,03
<0,001
Gender: Female vs. Male
0,94
0,5
Primary kidney disease (vs. Renal vascular diseases)
•
Glomerular nephropathies
•
Tubule-interstitial nephritis
•
Hereditary nephropathies
•
Diabetic nephropathy
•
Unknown/ Others
0,75
0,94
0,62
1,25
1,13
<0,001
<0,01
0,5
<0,001
0,01
0,1
35
International comparisons
The most recent reports published by USRDS
(2011) and EDTA ERA Registry (2012) were used for
comparison7,8.
Incident patients
In 2011, Romania continued to be below the
European average of the incident patients (127
vs. 130 pmi), but had one of the highest rates of
increase (66% vs. 6%) (Figure 28, see also Figure 29,
Figure 30).
The proportion of diabetic patients incident in
dialysis in Romania is one of the lowest in Europe. A
possible explanation could be the lack of resources
limiting the access to treatment of the patients
with diabetes mellitus and other comorbidities.
Considering that the rate of increase in dialysis
incident patients in Romania is one of the highest
in Europe, and the average of prevalent patients
approaches the European average, it would be
expected that the ratio of the incident diabetic
patients would also increase. However, this is not
the case: the rate of increase of in the proportion
of incident diabetic patients in Romania is one
of the lowest in Europe). Accordingly, either the
prevalence of diabetes is overestimated in Romania,
or the diabetic predialysis CKD patients’ mortality is
significantly higher (Figure 32, Figure 33).
Figure 28. Incident RRT patients in the Europe in 2011 (EDTA-ERA Registry 2011)
70%
6 0%
53%
50%
Percent
Although increasing, the average age of incident
patients in Romania is lower than in Europe or USA
(Figure 29).
4 0%
39 %
59 %
59 %
4 9 %
4 9 %
50%
4 2%
32%
30%
20%
10%
0%
Romania
Europa
2006
2010
SU A
2011
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
SU A
36 9
Japonia
6 6
288
Turcia
50
252
Portugalia
4 3
239
Republic Cehă
19 8
Belgia, olandeză
19 5
Belgia, franceză
19 2
Grecia
19 0
Franța
14 9
Croația
14 2
Austria
139
Marea Britanie
136
Bosnia
31
19
7
133
Europa ( ERA-EDTA)
130
România
124
Danemarca
121
Spania
121
Suedia
121
Olanda
118
România
I slanda
Rusia
Turcia
Marea Britanie
Republic Cehă
6
Europa ( ERA-EDTA)
5
Olanda
5
Japonia
4
Norvegia
3
Franța
3
Belgia, franceză
2
Danemarca
2
Belgia, olandeză
1
SU A
0
Croția
0
Bosnia
-4
Grecia
Norvegia
104
-5
Spania
I slanda
104
-6
Finlanda
9 9
-7
Suedia
Scoția
Finlanda
Rusia
81
4 0
Figure 30. Incident RRT patients in 2011 (pmi) (international comparison)
-13
-15
Austria
Scoția
Figure 31. Variation 2011/2006 (%) in incident RRT patients number (pmi)
(international comparison)
37
Republica Cehă
24 .8%
Finlanda
24 .2%
Portugalia21.2%
14 .3%
Austria
13.8%
Croația
7.6 %
7.0%
Grecia
4 .1%
Marea Britanie
2.3%
Spania
-0.5%
-1.8%
Boznia
-2.4 %
Suedia
-6 .6 %
-7.0%
Scoția
-8.5%
Danemarca
-10.1%
Franța
-12.1%
-13.4
% ( ERA-EDTA)
Europa
37.9 %
I slanda
35.0
Rusia
34 .6
Marea Britanie
Bosnia
31.5
Croația
30.1
Danemarca
30.0
Scoția
România
29 .2
Spania
25.6
Franța
24 .6
Europa ( EDTA-ERA)
Finlanda
24 .3
Olanda
23.8
Belgia ( olandeză)
Suedia
23.3
Grecia
23.0
Belgia ( franceză)
21.6
Austria
Norvegia
21.5
Belgia ( olandeză)
21.0
Belgia ( franceză)
20.7
Norvegia
Rusia
I slanda
17.1
15.8
15.2
37.9 %
24 .8%
Rusia
24 .2%
Marea Britanie
21.2%
-0.5%
Bosnia
14 .3%
Croația
13.8%
Danemarca
7.6 %
Scoția
7.0%
România
4 .1%
2.3%
I slanda
Spania
Franța
Europa ( EDTA-ERA)
-1.8%
Finlanda
-2.4 %
Olanda
-6 .6 %
Belgia ( olandeză)
-7.0%
Suedia
-8.5%
-10.1%
Grecia
Belgia ( franceză)
Romania
14 .2
-12.1%
Austria
Olanda
14 .1
-13.4 %
Norvegia
Figure 32. The proportion of diabetic patients incident in RRT in 2011
(international comparison).
Figure 33. Variation 2011/2006 (%) of the proportion of diabetic patients
incident in RRT (international comparison)
38
80%
74 .3%
70%
6 0%
50%
Prevalent patients
Even though it increased rapidly after 2006, the
number of prevalent RRT patients 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 continues to be one
of the highest among the European countries and
it is 3 times 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).
Europe ( 2011)
50.8%
4 1.6 %
4 0%
Romania ( 2013)
30%
19 .6 %
20%
7.6 %
10%
0%
HD
6 .1%
DP
TR
Figure 34. The proportions (%) of prevalent patients treated by hemodialysis (HD),
peritoneal dialysis (DP) and renal transplantation (TR) in Europe and Romania
100%
9 3.3%
79 .0%
75%
Europe ( EDTA)
50%
Romania
25%
15.4 %
5.7%
0%
HD
DP
5.6 %
1.0%
TR
Figure 35. The proportions (%) of incident patients treated by hemodialysis (HD),
peritoneal dialysis (DP) and renal transplantation (TR) in Europe and Romania
39
Japonia
2, 309
SU A
1, 9 24
Belgia, franceză
1, 271
Republica Cehă
România
1, 184
Turcia
Grecia
1, 103
I slanda
Franța
1, 09 1
Bosnia
1, 075
Austria
1, 001
Croația
9 80
Republica Cehă
Olanda
Suedia
104 .8%
Rusia
Belgium, olandeză
Spania
110.9 %
50.9 %
4 7.4 %
37.3%
27.7%
Olanda
24 .5%
Marea Britanie
20.5%
Belgia, franceză
18.6 %
9 74
Japonia
18.1%
9 6 1
Norvegia
16 .1%
SU A
15.7%
9 30
Norvegia
874
Belgium, olandeză
14 .6 %
Marea Britanie
871
Croația
14 .5%
Turcia
86 8
Franța
13.3%
Danemarca
851
Grecia
11.9 %
Scoția
84 2
Spania
11.8%
Finlanda
10.4 %
Austria
10.2%
Suedia
9 .3%
Danemarca
8.8%
Scoția
7.4 %
Finlanda
803
Bosnia
705
I slanda
6 6 5
România
Rusia
6 24
19 6
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
Figure 37. Variation 2011/2006 (%) in number prevalent patients undergoing
RRT (international comparison)
40
As compared to the trends in the European
countries in 2011/2006, Romania has recorded a
higher increase in the percentage of hemodialysis
patients, a higher decrease in the percentage
of peritoneal dialysis patients and a significant
increase of the prevalent transplanted patients
(Figure 38).
• Romania has one of the lowest prevalence
rates of the patients 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 transplantation and
are used at similar rates.
• Patients with functional kidney graft have a
lower prevalence in Romania, but the rate
of increase rate was one of the highest in
Europe.
Norvegia
Portugalia
Olanda
Spania
Suedia
Austria
Franța
Finlanda
Marea Britanie
Danemarca
Cehia
Croția
Grecia
Romania ( 2012)
Serbia
Turcia
Bosnia Herțegovina
Rusia
4 6
4 2
0
100
336
221
126
102
9 5
200
39 9
39 0
300
4 00
4 34
538
520
500
4 83
4 74
500
6 29
6 10
577
6 00
700
Patients with a functional kidney graft (per million inhabitants)
Figure 38. Variation 2011/2006 (%) in prevalent RRT patients number in Europe and in Romania
(HD – hemodialysis; DP – peritoneal dialysis; TR – renal transplantation)
TR
23.0%
-37.0%
DP
-20.6 %
8.8%
HD
-50.0%
138.0%
3.5%
0.0%
50.0%
Romania
100.0%
150.0%
Europe
Figure 39. Trends of the use of renal replacement therapy methods in Europe
and in Romania (variance 2011/2006, in percentage)
41
Survival on RRT
A cohort of dialysis patients who started the therapy in 2006-2010 in Romania (N=10.588) was comparatively analyzed with corresponding data reported by
EDTA-ERA Registry. The unadjusted survival rate of the patients treated in Romania is lower within the first three months, but significantly better after one
and two years, which emphasizes once again the deficiencies in the care before starting the dialysis (Table XII, Figure 40).
Table XII. Unadjusted survival rate at 90 days, 1 year and 2 years for the cohort 2006-2010, incident dialysis patients in Europe and Romania
Parameter
Age groups (years)
• 0-19
• 20-44
• 45-64
• 65-74
• 75+
90 days
1 year
2 years
EDTA-ERA
RRR
EDTA-ERA
RRR
EDTA-ERA
RRR
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
94.1 (93.3-94.2) 91.3 (90.5-92.0) 82.4 (82.1-82.6)
84.6 (83.6-85.5)
70.4 (70.1-70.6)
77.8 (76.8-78.7)
• Female
93.5 (93.3-93.7) 92.6 (91.8-93.3) 81.7 (81.4-82.1)
86.1 (85.1-87.0)
70.2 (69.8-70.5)
79.2 (78.0-80.3)
Primary kidney disease
71.4 (69.0-73.7)
69.1 (68.6-69.5)
82.3 (80.3-84.2)
• Diabetic nephropathy
95.0 (94.7-95.2) 91.4 (89.8-92.9) 82.9 (82.5-83.3)
75.0 (71.8-78.1)
67.5 (67.0-68.0)
83.0 (80.4-85.5)
• HBP/Renal vascular disease
94.2 (93.9-94.5) 92.1 (90.1-94.0) 81.3 (80.8-81.8)
84.1 (83.5-84.7)
86.1 (84.3-87.8)
91.1 (89.7-92.4)
97.3 (97.0-97.6) 95.8 (94.8-96.7) 91.2 (90.7-91.7)
• Glomerulonephritis
69.8 (69.5-70.1)
78.4 (77.4-79.3)
84.7 (83.9-85.4)
92.9 (92.7-93.1) 91.0 (90.2-91.7) 80.8 (80.5-81.1)
• Other causes/ not specified
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)
100%
9 3.9 %
9 1.9 %
82.1%
80%
• Romanian dialysis patients’ chances
of survival are lower in the first 90
days, but better after 1 and 2 years,
as compared to data reported by the
EDTA-ERA Registry.
EDTA-ERA
Ro
85.3%
70.3%
78.4 %
6 0%
4 0%
20%
0%
9 0 days
1 year
2 years
Figure 40. Unadjusted
survival rates of incident
dialysis patients in the
period 2006-2010 in
Europe (EDTA-ERA) and in
Romania (all differences
are significant)
42
Table XIII. Dialysis centers and prevalent patients by provider in Romania (2012/2011)
Dialysis providers
Prevalent dialysis patients on 31.12
Centers
The number of the dialysis centers has not changed.
The public sector owns most of the centers (42%).
Public centers treated 11% dialysis patients. The
most important private provider of dialysis services
was Fresenius Nephrocare, followed by International
Helathcare Systems, Diaverum, Avitum (45%, 14%,
11% and 9%) (Table XIII, Figure 41).
HD
PD
Total
2012
2013
2012
2013
2012 2013 2012
Public
57
57
1125
1137
136
Avitum
8
8
827
998
31
44
Diaverum
10
10
868
1178
52
70
Fresenius Nephrocare
35
35
4543
4714
International Healthcare systems
13
13
1108
1192
Other
14
14
1080
1103
109 1261
2013 Variation*
1246
-1.2%
859
1042
21.3%
920
1248
35.7%
336
281 4879
4995
2.4%
325
323 1433
1515
5.7%
38
27 1118
1130
1.1%
*2013 vs. 2012, in percentage
Others
10%
IHS
14%
Public
11%
4 0%
Av itum
9%
D iav erum
11%
FNC
45%
Figure 41. The ratio of the dialysis service providers
on 31.12.2013 (percentage from the total number
of prevalent patients)
All private providers of dialysis have recorded increases
in the number of treated patients. Diaverum and
Avitum had the highest rate of in-crease (Figure 42).
35.7%
35%
30%
25%
21.3%
20%
15%
10%
5.7%
5%
0%
-5%
2.4 %
1.1%
-1.2%
Public
Avitum
Diaverum
FNC
IHS
Alții
Figure 42. Variation in prevalent patients’ number 2013/2013 (%) by dialysis service provider
43
The percentage of patients treated in the public centers
continued to decrease and reached the lowest level in
2007 (11%) (Figure 42, Figure 43). Since public centers
in hospitals function as a support for the ambulatory
centers, public dialysis stations should be maintained,
at least in the county hospitals. On the other hand,
policies regarding the privatization/re-privatization of
the public stations should be discouraged, in order to
prevent unfair competition.
There were differences in the use of the PD by dialysis
providers. In general, PD is preferred only by some of
the private providers (International Healthcare Systems,
Fresenius) and by the public sector. In 2013, most of the
providers recorded a decrease in prevalent PD patients.
The increases recorded by Avitum and Diaverum were
not enough to stop the decline in PD usage in Romania
(Figure 44, Figure 45).
The continuous decrease in PD usage noticed in the
public sector (-20%) is alarming, as it regards the area
where the renal replacement therapy is chosen and
initiated. One of the causes is that the costs for the
initiation 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 initiate renal replacement therapy, but
also on programs for predialysis Chronic kidney disease
care.
5
9 5
13
87
30
2007
2008
88
12
12
8
2011
2012
2013
84
70
16
2009
2010
Public
9 2
88
Private
Figure 43. The proportion of dialysis patients treated in the public sector (%)
Other
8%
Others
8%
Public
18%
Avitum
5%
Public
18%IHS
32%
IHS
32%
Avitum
5%
Diaverum
6 %
FNC
Diaverum
31%
6 %
FNC
31%
Figure 44. The proportion of PD patients by dialysis providers
(percentage of the total num-ber of dialysis patients)
44
50%
4 1.9 %
4 0%
34 .6 %
30%
• Private providers treated 88% of the dialysis
patients.
• The public sector treated about 12% of the
dialysis patients. Since public, hospital based
sector functions as a support for the private
ambulatory centers; a further decrease in the
proportion of patients treated in the public
centers is risky.
20%
10%
0%
-0.6 %
-10%
-20%
-30%
-4 0%
-16 .4 %
-19 .9 %
-28.9 %
Public
Avitum
Diaverum
FNC
I HS
Others
-26 .0%
Romania
Figure 45. The trends in peritoneal dialysis usage by dialysis providers in Romania
(PD prevalent patients 2012/2006 in percentage)
45
150
Organization and �inancing
Privatization and the public sector
After the initiation of the privatization (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 existing in hospitals were
transformed into dialysis stations 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 patients, which otherwise would have
died, could be treated. The number of dialysis
patients doubled, but the costs per treated patient
decreased since 2004 until 2013 by 19.4% (Figure
47). Accordingly, privatization allowed for increasing
the economic efficiency of the dialysis program.
• Privatization allowed to treat more patients
by an increase in the economic efficiency of
the dialysis program.
Most of the dialysis centers originally located
in hospitals were converted into public dialysis
stations with 4-8 machines. These stations initiate
RRT and ensure the therapy for dialysis patients
requiring hospital admission. Unfortunately, the
process lead to the disappearance of the dialysis
stations in some counties (CL, CV, GR, MH).
120
9 0
134
106
6 0
30
71
70
8
1
0
2004
2005
137
138
3
4
85
69
0
2006
74
5
2007
29
22
11
12
2008
2009
New centers
2010
2011
2012
2013
Total
Figure 46. Dialysis centers in Romania (2004-2012)
20, 000
16,611
16,021
16,449
17,263
15,841
13,861
15, 000
10, 000
6 , 034
6 , 283
6 , 715
6 , 9 86
0
3, 6 4 4
3, 888
4 , 028
2004
2005
2006
2007
Patients
9 , 09 7
14,013
9 , 755
8, 371
8, 4 24
4 , 880
4 , 9 51
5, 389
5, 79 6
2008
2009
2010
2011
5, 000
3, 508
14,071
Program buget (thousands RON)
14,604
10, 4 70
Costs
-19%
13,910
11, 176
Patients
+100%
6 , 819
6 , 871
2012
2013
Costs per treated patient (EURO)
Figure 47. The number of patients benefiting 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
17, 000
TR, 20%
TR, 42%
8%
74%
51%
Europe ( EDTA)
The ratio between RRT methods
Compared 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 differs - HD is the most expensive, and
RTx is the least - the current combination of
the methods leads to higher average costs per
patient under-going renal replacement therapy
(Figure 48).
Sp endings p e year ( million RON)
• Establish rules for the deduction of dialysis
sessions performed in hospital at the initiation
of therapy and for admitted dialysis patients;
• Allocate around 5-10% of the program funds for
these sessions.
12, 500
Romania
HD
D P
11, 750
TR
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)
Since the public sector in hospitals is critical for
the dialysis program, it is necessary to:
• Introduce the health card for the patients in
the program, which would facilitate treat-ment
records.
7%
C heltuieli/ an ( Euro)
The public sector in hospitals is critical for running
the dialysis program, since private centers
function as ambulatory centers and dialysis
patients frequently suffer from comorbidities
requiring hospital admission. However, the
financing of this segment is deficient: even
though hospitals can contract dialysis services,
not all County HIH accept to deduct the costs for
the initiation of the treatment, and the therapy
sessions performed for hospitalized dialysis
patients are not fully reimbursed.
After 5 years, savings amount 10% per year,
allowing new patients to be treated without
an increase in the budget for the dialysis program
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% (Mod-el 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
Treatment quality
Moreover, from both a medical and an economical perspective, it would be ideal to
combine PD with RTx, and to initiate HD only in those patients who have no indications
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 ratio of incident
peritoneal dialysis patients and to 400 kidney grafts per year shows that after 5 years
the obtained savings would allow newly-included patients to be treated without
increasing the dialysis program budget (Figure 49).
To improve patients’ allocation to RRT methods, the following are needed:
• Programs addressing pre-dialysis CKD patients care;
• Financing at least 400 grafts per year (eventually, unlimited number of grafts);
• Conditioning the reimbursement of medicine costs in the post-renal transplantation
program by reporting to the Romanian Renal Registry, similar to the dialysis program.
• Increasing tariffs for peritoneal dialysis.
There is no system to assess the therapy
performances, although such a system was one
of the prerequisites for the initiation of the
privatization, and most of the private providers
have implemented quality management systems.
Moreover, a differentiated payment of services
based on the quality assessment can in perspective
be introduced .
Collecting data on medical performance by
Romanian Renal Registry would allow obtaining
information on the quality assessment and
requires:
• to establish compulsory reporting of quality of
therapy parameters by the providers;
• to properly reorganize and finance the Romanian
Renal Registry.
48
Table XIV. Weighted influences on the expenses of the Pro-gram for dialysis renal replacement
a)
Haemodialysis
Nature of cost
Prices of the dialysis services
The dialysis therapy is contracted as a package of
services per a hemodialysis session, respectively per
1 year of therapy for peritoneal dialysis. The package
includes the necessary consumables (dialysis
solutions, bloodlines, fistula needles dialyzer, etc.),
medicines (heparin, epoetins, iron, phosphate
chelating agents, vitamin D analogues, cinacalcet),
lab tests, patient transportation, 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 influences
significantly increased the costs of dialysis: the
increase of the VAT by 4%, the increase of the price
of medicines and introduction of new medicines
(cinacalcet, paricalcitol), 10% for hemodialysis
and 15% for peritoneal dialysis (new solutions 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 confidential
nature. That is why the impact analysis can only be
performed by a weighted calculation. The weighted
calculation 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 solutions,
which are more expensive (Table XIV).
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%
Transportation
10.4%
5.0%
0.5%
Wage costs
25.7%
9.0%
2.3%
100.0%
-
13.2%
Weight within
the expenses (%)
Increase (%)
Weighted increase (%)
3.4
18.1%
0.6%
Dialysis solutions
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%
Solutions transportation
7.4
5.0%
0.4%
0.7%
0.7%
8.1
9.0%
0.7%
100.0
-
24.2%
Total
b)
Peritoneal dialysis
Nature of cost
PD materials
Patient transportation
Wage costs
Total
-
The increase of Leu/EURO exchange rate, the increase of VAT, of cost of medicines (including the
introduction of new preparations) and of the wages increased the costs of dialysis therapy. Since
the increase of expenses directly reflects on the quality of therapy, it is necessary to increase
prices by 10-13% for HD and by 15-20% for PD.
49
Conclusions
1. Chronic kidney disease has a higher prevalence in Romania that in the
USA: 13.1% vs. 11.5%; the estimated number of adult persons with CKD
in Romania is about 1,900,000.
2. Since the number of CKD patients with medium-high risk is 565,000, a
nephrologist should care approximately 1,900 patients.
3. CKD patients suffer more often from diabetes mellitus, HBP, strokes and
heart failure, and their death risk is twice higher. Consequently, CKD care
should be multidisciplinary (diabetology, cardiology and nephrology).
4. The medical assistance is mainly provided in hospital (over a quarter of
the patients are admitted into hospital), regardless of the state of the
kidney, and the CKD patients have almost twice as many visits in the
ambulatory clinic. Thus, it is necessary to organize multidisciplinary CKD
medical care programs that must promote ambulatory care.
5. The framework contract for 2014 included stipulations in favor of the
multidisciplinary care of CKD patients in the ambulatory clinic, but the
Application norms are relatively less precise and cannot be implemented,
since the 10th version of the International Classification of Diseases
used in Romania is not updated to include Chronic kidney disease (N18).
Temporarily, until it is brought up-to-date, we suggest accepting the N18
code (in the current classification - Chronic kidney failure) for the Chronic
kidney disease in hospital admittance cases and the code 685 in the
ambulatory patients.
6. The number of the RRT patients 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 patients’ number is 7-8% and shall only
decrease in 2016-2017, when most of the existing patients 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 patients number estimated for 2014-2015 is
6-7%.
b. In 2014, 11,600 patients shall be treated by dialysis, and in 2015,
12,200.
c. In 2014 there will be 3,100 newly included patients, 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 patients before dialysis initiation;
b. Programs addressing the physicians in hospitals and in the specialty
ambulatory departments;
c. Adjusting the prices for peritoneal dialysis.
9. Renal transplantation:
a. The number of grafts increased and the grafts from deceased donors
were predominant in the incident transplant patients, but only 8% of
incident patients undergone non-preemptive transplantation;
b. At least 300-400 grafts would be necessary each year in order to
allow transplantation to contribute effectively to RRT in Romania.
On principle, the number of grafts for which the costs are deducted
should not be limited, as wasting the available grafts from financial
reasons is meaningless;
c. The post-transplantation program shall include 2989 and respectively
3255 patients for the years 2014 and 2015.
d. In order to have a proper evidence of RTx patients, compulsory
reporting of the transplant patients to the Romanian Renal Registry
50
should be introduced, by conditioning the deduction of 100%
deducted prescription for the patients in the post-transplantation
program by reporting.
10. Hemodiafiltration and automated peritoneal dialysis treatments are less
frequently used. In order to use them more efficiently it is indicated to
change the currently accepted by NHIH prescription 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 counties IL, CL, GR, OT, MS, CV) continue to have
a lower coverage with dialysis facilities and low perspectives for
improvement.
b. The indications of the use of renal replacement therapy methods
significantly vary from one area to another: in the center of
Transilvania, hemodialysis and renal transplantation 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 transplantation is rare.
12. The characteristics of the incident RRT Romanian patients are changing
and are converging to European incident patients’ characteristics: the
age and the proportions of patients with diabetes mellitus and cardiovascular comorbidities are increasing.
13. Nephrology care before initiating dialysis seems to be deficient: the
proportion of patients without a known diagnosis of the primary kidney
dis-ease tends to decrease, but is still too high, which emphasizes the
need for programs addressing predialysis CKD patients.
14. There is no system for assessment of medical performance of the dialysis
centers. Collecting data on the medical performance at Romanian Renal
Registry would allow to obtain information for the quality assessment
and requires:
a. to establish compulsory reporting of the quality of therapy parameters
by the dialysis providers;
b. to properly reorganize and finance 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 critical for the dialysis program. That is why it is necessary to:
a. redefine rules for the deduction of dialysis sessions performed in
hospital at the initiation of therapy and for admitted dialysis patients;
b. introduce the health card for the patients in the program to facilitate
proper treatment records;
c. allocate around 5-10% of the program funds for these sessions.
16. Privatization allowed treating more patients by increasing the economic
efficiency of the dialysis program. Practically, the costs per treated patient
decreased by 19% since 2004 until 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
solutions) and of the wages increased the costs of dialysis therapy. Since
the increase of expenses directly reflects on the quality of therapy, it is
necessary to increase prices by 10-13% for hemodialysis and by 15-20%
for peritoneal dialysis.
51
Appendices
Appendix 1. The method for the calculation of the standardized mortality ratio
National reference mortality rates were calculated on a cohort of 11,829 hemodialysis patients alive on January 1st 2010, monitored over a 3-year period.
Patients who started hemodialysis 90 days before January 1st were excluded, and those who received renal transplantation or were no longer included in the
records in the observation period were censored.
As the major determinants of mortality are age and primary kidney disease (especially diabetic nephropathy), the national mortality rates were calculated by
8 age groups and 4 etiologies, including diabetes mellitus, in relation to the frequency of the primary kidney diseases reported in Romania)9.
By using these national rates, the expected number of deaths in a certain population can be calculated. The standardized mortality ratio is the ratio between
the expected number of deaths noticed in the respective population and the expected ratio. 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 national average
mortality rate, which does not necessarily correspond to an optimum care. On the other hand, due to the diversity and the multiple comorbidities of the
hemodialysis patients, the SMR must also be interpreted with care, as an orienting comparison. Thus, a center can provide an excellent care to a subgroup of
patients and a deficient care to another subgroup, which would lead to a SMR of almost 1.00 by cancelling the two effects.
Accordingly, SMR is only an orienting parameter, which can indicate a care issue when the value is below 1, without allowing the identification of causes and
imposing additional analyses.
52
Appendix 2. The method of calculation of the survival rates
The data regarding the evolution of HD and PD patients were obtained from the Romanian Renal Registry, and those related to the survival of (preemptive
and non-preemptive) RT patients were obtained from the “Fundeni” Clinical Institute.
The data included 9,540 adult incident patients 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 patients lost to follow-up were
censored. The characteristics of the investigated patients are presented in Table XV.
Table XV. The characteristics of the patients investigated for the survival analysis
Number of patients
Male (%)
Total
TR
HD
PD
9540
490
8050
1000
57
64
58
51
Primary kidney disease (%)
• Glomerulonephritis
• Tubule-interstitial nephritis
• Hereditary nephropathies
• Diabetic nephropathy
• Renal vascular diseases
• Unknown/ Others
17
12
6
14
7
44
42
9
6
7
1
35
16
12
6
14
7
14
16
13
5
17
12
37
Death causes (%)
• Cardio-vascular
• Neoplasia
• Infectious
• Gastrointestinal
• Other causes/ unknown
48
3
3
2
44
17
41
34
8
48
3
3
2
44
47
2
2
1
48
p
<0,001
<0.001
<0.001
The unadjusted survival rates were calculated (Kaplan Meier), which were subsequently adjusted in a Cox logistic regression model.
53
Appendix 3. Dialysis centers, machines and patients treated on a machine in the counties of Romania in 2012, 2013 and variance 2013/2012 (in percentage)
County
Population
HD patients
2012
AB
342,376
Dialysis centers
2013
Variance
No
pmi
No
pmi
168
491
192
561
14.3%
2012
2013
HD machines
Variance
No
pmi
No
pmi
1
2.9
2
5.8
100.0%
2012
2013
Variance
No
pmi
Patients/
machine
No
pmi
Patients/
machine
39
114
4.3
40
116.8
4.8
Ap
2.6%
Variance
machine
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%
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%
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%
B + IF
BC
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%
54
County
Population
HD patients
2012
OT
436,400
Dialysis centers
2013
Variance
No
pmi
No
pmi
146
335
163
374
11.6%
2012
2013
HD machines
Variance
No
pmi
No
pmi
2
4.6
2
4.6
0.0%
2012
2013
Variance
No
pmi
Patients/
machine
No
pmi
Patients/
machine
27
62
5.4
35
80.2
4.7
Ap
Variance
machine
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
Romania
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%
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%
55
Appendix 4. Dialysis patients registered on 31.12.2012 and 31.12.2013 in the counties of Romania and the variance 2013/2012 (in percentage)
County
Population
HD patients
2012
2013
Variance
No
pmi
No
pmi
PD patients
2012
2013
Variance
No
pmi
No
pmi
Total
2012
2013
Variance
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%
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%
B + IF
56
County
Population
HD patients
2012
2013
Variance
No
pmi
No
pmi
PD patients
2012
2013
Variance
No
pmi
No
pmi
Total
2012
2013
Variance
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%
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%
Romania
57
Appendix 5. Patients incident in hemodialysis (HD), peritoneal dialysis (PD), non-preemptive renal transplantation (TR) and the number of deaths in 2013 in the counties of Romania
County
Population
HD + PD patients
prevalent
patients**
Average
pmi
Newly included patients 2013
HD
PD
PD/HD
No
No
%
Deaths 2013
HD+DP
No
%
TR
pmi
No
No
%
%
pmi
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
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
B + IF
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
58
County
Population
HD + PD patients
prevalent
patients**
Average
pmi
Newly included patients 2013
HD
PD
PD/HD
No
No
%
Deaths 2013
HD+DP
No
%
TR
pmi
No
No
%
%
pmi
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
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
Romania
*12 month average for the year 2012
59
Appendix 6. Prevalent patients in the dialysis centers in Romania on 31.12.2011 vs. 31.12.2010 and the variance 2012/2011 in percentage (in the alphabetical order of the counties)
Dialysis Center
County
Prevalent patients1
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.
7.
Hemo-Vest – Arad
Arad County Clinical Emergency Hospital
AR
AR
149
30
157
30
5.4%
0.0%
6
1
3
0
-50.0%
-100.0%
155
31
160
30
3.2%
-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 Institute - Pediatric Dialysis
B
5
9
80.0%
8
5
-37.5%
13
14
7.7%
12.
13.
Fundeni Clinical Institute - Renal transplantation
"N. Paulescu” Institute for Nutrition and Metabolic
Diseases
B
8
8
0.0%
0
0
-
8
8
0.0%
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.
21.
Nefro Care Center Bucuresti
“Dr Carol Davila” Clinical Nephrology Hospital - Bucharest
B
72
98
36.1%
4
2
-50.0%
76
99
30.3%
B
19
37
94.7%
12
11
-8.3%
31
47
51.6%
22.
23.
"Sf. Ioan" Clinical Emergency Hospital Bucharest
"Grigore Alexandrescu" Children Clinical Emergency
Hospital
B
28
21
-25.0%
0
0
-
28
21
-25.0%
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
-
60
Dialysis Center
County
Prevalent patients1
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 station
BC
0
36
-
0
0
-
0
36
-
30.
Renal Med Bacau Onesti
BC
61
60
-1.6%
0
0
-
61
60
-1.6%
31.
32.
Bacau County Emergency Hospital
Moinesti Dialysis station
BC
BC
26
39
17
0
-34.6%
-100.0%
0
0
0
0
-
26
39
17
0
-34.6%
-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 station 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%
61
Dialysis Center
County
Prevalent patients1
HD
2012
2013
PD
HD + PD
Variance
2012
2013
Variance
2012
2013
Variance2
53.
Cluj Children Clinical Emergency Hospital - Nephrology 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.
65.
Avitum Sf. Gheorghe
"Dr. Fogolyan Kristof" County Emergency Hospital
Covasna
CV
43
84
95.3%
1
1
0.0%
44
85
93.2%
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.
77.
"Sf. Ioan" Clinical Children Emergency Hospital Galati
"Sf. Ap. Andrei" County Clinical Emergency Hospital
Galati
GL
8
7
-12.5%
0
0
-
8
7
-12.5%
GL
19
20
5.3%
7
4
-42.9%
26
24
-7.7%
62
Dialysis Center
County
Prevalent patients1
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 Marmatiei
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%
63
Dialysis Center
County
Prevalent patients1
HD
2012
PD
2013
Variance
2012
2013
HD + PD
Variance
2012
2013
Variance2
104.
Neamt County Emergency Hospital Piatra Neamt
NT
3
1
-66.7%
0
0
-
3
1
-66.7%
105.
Nefrolab Slatina
OT
108
137
26.9%
2
4
100.0%
110
141
28.2%
106.
Olt Slatina 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.
122.
NEFROMED BM Radauti
"Sf. Ioan cel Nou" County Emergency Hospital Suceava
SV
48
53
10.4%
1
1
0.0%
49
52
6.1%
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.
127.
128.
Nefromed Dialysis Center Timisoara
"Louis Turcanu" Children Emergency Hospital
Timis County Hospital and Renal transplantation Clinic Timisoara
TM
TM
181
0
170
0
-6.1%
-
8
1
16
0
100.0%
-100.0%
189
1
186
0
-1.6%
-100.0%
TM
23
16
-30.4%
0
1
-
23
17
-26.1%
129.
Lugoj Town Hospital - Dialysis station
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%
64
Dialysis Center
County
Prevalent patients1
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.
136.
IHS Focsani
"Sf. Pantelimon" Vrancea County Emergency Hospital,
Focsani
VN
144
161
11.8%
54
55
1.9%
198
216
9.1%
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%
10.470
11.158
6.6%
Romania
1
2
9.551
10.322
8.1%
919
854
-7.1%
- Patients registered on 31.12.2012 and 31.12.2013
- Variance in percentage 31.12.2013 vs. 31.12.2012
65
Appendix 7. Prevalent and incident dialysis patients, non-preemptive transplanted or deceased patients in dialysis centers in Romania in 2013 (in the alphabetical order of the counties)
Dialysis center
County
Prevalent patients*
HD
PD
Newly-included patients
PD/HD HD+DP HD
%
PD
PD/HD
Deaths
HD+DP
TR
No
No
No
No
No
%
No
%
%
No
1.
2.
Nefromed Dialysis Centers - Alba-Iulia
Alba-Iulia County Emergency Hospital - Haemodialysis department
AB
178
3
1.7%
181
11
0
0.0%
11
6.1%
No
1
0.6%
18
%
9.9%
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 Institute - Pediatric Dialysis
B
8
8
97.8%
15
2
0
0.0%
2
13.2%
0
0.0%
0
0.0%
12.
13.
Fundeni Clinical Institute - Renal transplantation
"N. Paulescu” Institute for Nutrition and Metabolic
Diseases
B
8
0
0.0%
8
49
0
0.0%
49
612.5% 112 1400.0%
0
0.0%
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.
21.
Nefro Care Center - Bucharest
"Dr. Carol Davila" Clinical Nephrology Hospital – Bucharest
B
93
4
3.9%
97
0
0
-
0
0.0%
0
0.0%
9
9.3%
B
32
12
37.7%
44
172
16
9.3%
188
428.9%
0
0.0%
11
25.1%
22.
23.
"Sf. Ioan" Clinical Emergency Hospital Bucharest
"Grigore Alexandrescu" Children Clinical Emergency
Hospital
B
18
0
0.0%
18
110
0
0.0%
110
614.0%
0
0.0%
20
111.6%
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 Institute - Nephrology
B
11
12 109.1%
23
43
14
32.6%
57
247.8%
0
0.0%
4
17.4%
66
Dialysis center
County
Prevalent patients*
HD
PD
No
No
B
10
SUUB University Emergency Hospital Bucharest
B
Fresenius NephroCare Bacau
BC
26.
"Marie Curie" Children Emergency Hospital Bucharest
27.
28.
Newly-included patients
PD/HD HD+DP HD
PD
PD/HD
Deaths
HD+DP
%
TR
%
No
No
No
No
%
No
%
No
%
0
0.0%
10
4
0
0.0%
4
40.0%
0
0.0%
0
0.0%
44
2
4.6%
46
133
3
2.3%
136
298.9%
0
0.0%
44
96.7%
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 station
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 station 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%
67
Dialysis center
County
Prevalent patients*
HD
PD
No
No
Newly-included patients
PD/HD HD+DP HD
PD
PD/HD
%
No
No
No
Deaths
HD+DP
%
TR
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.
65.
Avitum - Sf. Gheorghe
"Dr. Fogolyan Kristof" County Emergency Hospital
Covasna
CV
62
1
1.6%
63
5
0
0.0%
5
8.0%
1
1.6%
7
11.1%
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%
0
73.
Diaverum - Tg. Jiu
GJ
62
4
5.6%
66
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 station 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.
78.
"Sf. Ioan" Clinical Children Emergency Hospital Galati GL
"Sf. Ap. Andrei" County Clinical Emergency Hospital
Galati
GL
7
0
5.6%
8
0
0
-
0
0.0%
1
12.8%
0
0.0%
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%
68
Dialysis center
County
Prevalent patients*
HD
PD
No
No
Newly-included patients
PD/HD HD+DP HD
%
PD
PD/HD
No
No
No
Deaths
HD+DP
%
TR
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 Marmatiei
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 - Slatina
OT
129
3
2.6%
133
1
0
0.0%
1
0.8%
0
0.0%
17
12.8%
107.
Olt Slatina 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%
69
Dialysis center
County
Prevalent patients*
HD
PD
No
No
Newly-included patients
PD/HD HD+DP HD
%
PD
PD/HD
No
No
No
Deaths
HD+DP
%
TR
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%
1
1.1%
1
1.1%
14
15.8%
27 1012.5%
0
0.0%
4
150.0%
116.
NEFROMED SJ - Zalau
SJ
89
0
0.0%
89
1
0
0.0%
117.
Salaj - Zalau County Hospital
SJ
3
0
0.0%
3
27
0
0.0%
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.
123.
NEFROMED BM - Radauti
"Sf. Ioan cel Nou" County Emergency Hospital Suceava
SV
54
1
1.9%
55
0
0
-
0
0.0%
0
0.0%
3
5.5%
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.
137.
IHS – Focsani
VN
County Emergency Hospital "Sf. Pantelimon" Vrancea
- Focsani
VN
149
53
35.7%
202
0
0
-
0
0.0%
0
0.0%
13
6.4%
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.
140.
Nefromed Dialysis Centers – Barlad
"Elena Beldiman" Emergency Hospital of the Town
Barlad
VS
109
6
5.5%
115
0
0
-
0
0.0%
0
0.0%
18
15.7%
5
37
0
0.0%
37
792.9%
0
0.0%
6
128.6%
10900 2.644 155
5.9%
2.799
2.1% 1.487
13.6%
Romania
VS
5
0
0.0%
10.022
878
8.8%
25.7% 227
* Monthly average of prevalent patients in 2013
70
Appendix 8. Haemodialysis centers ordered increasingly by the standardized mortality ratio (SMR)
Prevalent
patients*
SMR
CI 95%
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 Marmatiei
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
154
0.58
0.25
0.9 Low
International Healthcare Systems S.A - "Sf. Pantelimon" Bucharest
92
0.56
0.15
0.96 Low
S.C. Nefrolab S.R.L. - Dialysis center Slatina
87
0.56
0.15
0.96 Low
167
0.49
0.21
0.76 Low
49
0.49
0.02
0.96 Low
327
0.62
0.38
0.86 Low
Olt County Emergency Hospital - Haemodialysis center Slatina
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
International Healthcare Systems S.A. - Dialysis center Braila
98
0.63
0.19
1.08 Similar
117
0.65
0.23
1.07 Similar
38
0.67
-0.09
1.44 Similar
152
0.69
0.29
1.1 Similar
SC Diaverum Romania SRL - Unit Tg. Jiu
55
0.7
0.04
1.37 Similar
International 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
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
Hemodialysis center
Fresenius NephroCare Pitesti - Dialysis center
NEFROCARE MS Dialysis Center - Iasi
Fresenius NephroCare Bacau - Dialysis center
SC Diaverum Romania SRL - Roman Unit
Fresenius NephroCare "Dr. Carol Davila” - Dialysis center Bucharest
S.C. Nefromed Dialysis Centers SRL - Dialysis center Piatra Neamt
SC Diaverum Romania SRL- Dialysis center Sibiu
S.C. Renamed Dialcare SRL- Craiova
Fresenius NephroCare Brasov - Dialysis center
Significance†
71
Hemodialysis center
Prevalent
patients*
118
SMR
CI 95%
0.83
0.31
1.36 Similar
47
0.84
-0.03
1.7 Similar
127
0.84
0.34
1.34 Similar
33
0.86
-0.25
1.97 Similar
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
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
International 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
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
75
1.26
0.21
2.3 Similar
132
1.34
0.5
2.17 Similar
International 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 station
27
1.53
-0.61
3.67 Similar
SC HIPARION MED SRL Targu Mures
28
1.53
-0.62
3.69 Similar
SC Diaverum Romania SRL - Unit Bucharest – Industriilor
Constanta County Clinical Hospital - Haemodialysis center
Fresenius NephroCare Deva - Dialysis center
Avitum SRL - Dialysis center Sighisoara
S.C. Nefromed Dialysis Center SRL - Dialysis center Timisoara
Renal Care Group - Dialysis center Slobozia
S.C. VAMAGO SRL - Dialysis center Resita
Renal Care Group - Dialysis center Tulcea
SC Diaverum Romania SRL - Sibiu Unit
Significance†
72
Hemodialysis center
Baia Mare County Emergency Hospital - Haemodialysis center Baia Mare
Prevalent
patients*
45
SMR
CI 95%
Significance†
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
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
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
International Healthcare System S.A. - Dialysis center Petrosani
57
1.92
0.18
3.66 Similar
110
1.93
0.57
3.29 Similar
65
1.97
0.26
3.67 Similar
113
2.02
0.66
3.38 Similar
67
2.08
0.22
3.94 Similar
International Healthcare System S.A. - Dialysis center Buzau
S.C. Nefromed Dialysis Centers SRL - Dialysis center Satu Mare
Avitum SRL - Dialysis center Suceava
Craiova County Clinical Emergency Hospital - Dialysis center
SC Diaverum Romania SRL - Unit Bucharest - Splai Independentei
International Healthcare Systems S.A. - Dialysis center Galati
73
S.C. NEFROMED BM S.R.L. - Dialysis center Radauti
Prevalent
patients*
44
S.C. Diasys Medical SRL - Dialysis center Targoviste
Hemodialysis center
SMR
CI 95%
Significance†
2.09
-0.15
4.32 Similar
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
International 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
119
2.28
0.84
3.71 Similar
11
2.43
-2.81
7.67 Similar
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
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
7
2.75
-6.19
11.69 Similar
42
2.85
-0.29
5.99 Similar
8
2.86
-3.85
9.58 Similar
17
3.09
-2.23
8.41 Similar
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
4
3.72
-10.35
17.8 Similar
Timis County Hospital - Dialysis and renal transplantation 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 station
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 station
13
4.51
-4.88
13.91 Similar
S.C. Hemo-Vest SRL – Arad
Petrosani Emergency Hospital - "Wolfgan Steger” Haemodialysis center
"Marie Curie" Children Emergency Hospital Bucharest
Satu Mare County Hospital - Dialysis center
"Sf. Maria" Clinical Children Emergency Hospital Iasi
Bacau County Emergency Hospital - Haemodialysis station
"Elena Beldiman” Town Emergency Hospital - Dialysis center Barlad
Teleorman County Hospital - Dialysis center Alexandria
Sibiu County Clinical Emergency Hospital - Dialysis station
Caras Severin County Hospital - Resita
74
Hemodialysis center
Brasov County Clinical Emergency Hospital - Dialysis center
Prevalent
patients*
20
SMR
CI 95%
Significance†
5.11
-3.45
13.68 Similar
205
2.47
1.25
3.7 High
1
NE
NE
NE NE
11
NE
NE
NE NE
Fundeni Clinical Institute - Dialysis center
1
NE
NE
NE NE
Fundeni Clinical Institute - Pediatric department, Nephrology department and the Pediatric dialysis
department
6
NE
NE
NE NE
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
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 Institute - Renal transplantation department
15
NE
NE
NE NE
"Sf. Ioan" Clinical Emergency Hospital - Bucharest - Dialysis department
1
NE
NE
NE NE
International Healthcare System S.A. - Dialysis center Constanta
9
NE
NE
NE NE
26
NE
NE
NE NE
4
NE
NE
NE NE
8161
1.27
1.19
Fresenius NephroCare SRL - „CI Parhon” Clinical Hospital No. 2 Iasi
"Mavromati" County Hospital Botosani - Dialysis center
"N. Paulescu” Institute for Nutrition and Metabolic Diseases - Dialysis center
Dambovita County Emergency Hospital - Hemodialysis center Targoviste
Arges County Hospital - Dialysis center Pitesti
DIA MEDICAL PORT - Bucharest
S.C. MALP srl Moinesti - Dialysis station
ROMANIA
1.36 High
* Prevalent haemodialysis patients on 31.12.2012
† Low – Standardized mortality ratio (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 different from 1 (indicates a mortality rate similar to that of the reference cohort); NA – not assessed (too small number of patients or too small observation interval)
75
References
Cepoi V, Onofriescu M, Segall L, Covic A: The prevalence of chronic kidney disease in the general population 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, Constantinescu 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 Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney int (2013) Suppl. 3:1-150.
5
Mircescu G, Stefan G, Gârneaţă L, Mititiuc I, Siriopol D, Covic A: Outcomes of dialytic modalities 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, National Institutes of Health,
National Institute of Diabetes and Digestive 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 politică oficială sau interpretare a Guvernului SUA.
7
ERA-EDTA Registry: ERA-EDTA Registry Annual Report 2012. Academic Medical Center, Department of Medical Informatics, 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
Kidney J (2014) 7: 227–238.
9
Wolfe RA, Gaylin DS, Port FK, PJ Held, Wood CL: Using USRDS generated mortality tables to compare local ESRD mortality rates to national rates.Kidney Int (1992)
42:991—996
1
76