CLINICAL KIDNEY JOURNAL Clinical Kidney Journal, 2016, vol. 9, no. 3, 457–469 doi: 10.1093/ckj/sfv151 Advance Access Publication Date: 31 January 2016 Original Article ORIGINAL ARTICLE Renal replacement therapy in Europe: a summary of the 2013 ERA-EDTA Registry Annual Report with a focus on diabetes mellitus Anneke Kramer1, Maria Pippias1, Vianda S. Stel1, Marjolein Bonthuis2, José Maria Abad Diez3, Nikolaos Afentakis4, Ramón Alonso de la Torre5, Patrice Ambuhl6, Boris Bikbov7,8, Encarnación Bouzas Caamaño9, Ivan Bubic10, Jadranka Buturovic-Ponikvar11,12, Fergus J. Caskey13, Pablo Castro de la Nuez14, Harijs Cernevskis15, Frederic Collart16, Jordi Comas Farnés17, Maria de los Ángeles Garcia Bazaga18, Johan De Meester19, Manuel Ferrer Alamar20, Patrik Finne21, Liliana Garneata22, Eliezer Golan23, James G. Heaf24, Marc Hemmelder25, Kyriakos Ioannou26, Nino Kantaria27, Mykola Kolesnyk28, Reinhard Kramar29, Mathilde Lassalle30, Visnja Lezaic31, Frantisek Lopot32, Fernando Macário33, Angela Magaz34, Eduardo Martín-Escobar35, Wendy Metcalfe36, Mai Ots-Rosenberg37, Runolfur Palsson38,39, Celestino Piñera Celestino40, Halima Resic41 ́ , Boleslaw Rutkowski42, Carmen Santiuste de Pablos43, Viera Spustová44, Maria Stendahl45,46, Ariana Strakosha47, Gültekin Süleymanlar48, Marta Torres Guinea49, Anna Varberg Reisæter50, Evgueniy Vazelov51, Edita Ziginskiene52,53, Ziad A. Massy54,55, Christoph Wanner56, Kitty J. Jager1, and Marlies Noordzij1 1 Department of Medical Informatics, Academic Medical Center, ERA-EDTA Registry, University of Amsterdam, 1100 DE Amsterdam, The Netherlands, 2Department of Medical Informatics, Academic Medical Center, ESPN/ ERA-EDTA Registry, Universiteit van Amsterdam, Amsterdam, The Netherlands, 3Aragon Renal Registry, Zaragoza, Spain, 4Hellenic Renal Registry, Board of Registry, Coordination and Control of RRT, General Hospital of Athens ‘G. Gennimatas’, Athens, Greece, 5Public Health Directorate, Asturias, Spain, 6Swiss Dialysis Registry, Renal Division, Stadtspital Waid Zürich, Zurich, Switzerland, 7A.I. Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russian Federation, 8Department of Nephrology Issues of Transplanted Kidney, Received: October 20, 2015. Accepted: December 11, 2015 © The Author 2016. Published by Oxford University Press on behalf of ERA-EDTA. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 457 CLINICAL KIDNEY JOURNAL 458 | A. Kramer et al. Academician V.I. Shumakov Federal Research Center of Transplantology and Artificial Organs, Moscow, Russian Federation, 9Regional Transplant Coordination Office, Galicia, Spain, 10Department of Nephrology, Dialysis and Transplantation, Clinical Hospital Center Rijeka, School of Medicine University of Rijeka, Rijeka, Croatia, 11 Department of Nephrology, University Medical Center Ljubljana, Ljubljana, Slovenia, 12Medical Faculty, University of Ljubljana, Ljubljana, Slovenia, 13UK Renal Registry, Southmead Hospital, Bristol, UK, 14Information System of Regional Transplant Coordination in Andalucia (SICATA), Andalucia, Spain, 15Department of Internal Medicine, Riga Stradins University, Riga, Latvia, 16French-Belgian ESRD Registry, Brussels, Belgium, 17Catalan Renal Registry, Catalan Transplant Organization, Health Department, Generalitat of Catalonia, Barcelona, Spain, 18 Dirección General de Salud Pública, Servicio Extremeño de Salud, Consejería de Sanidad y Políticas Sociales, Junta de Extremadura, Spain, 19Department of Nephrology, Dialysis and Hypertension, Dutch-speaking Belgian Renal Registry (NBVN), Sint-Niklaas, Belgium, 20Técnico Registro de Enfermos Renales Comunitat Valenciana, Servicio de Estudios Epidemiológicos y Registros Sanitarios, Subdirección General Epidemiología, Dirección General Salut Pública, Consellería Sanitat, Valencian Region, Spain, 21Abdominal Center, Nephrology and Finnish Registry for Kidney Diseases, Helsinki University Central Hospital, Helsinki, Finland, 22“Carol Davila” University of Medicine and Pharmacy, “Dr C Davila” Teaching Hospital of Nephrology, Romanian Renal Registry, Bucharest, Romania, 23Department of Nephrology and Hypertension, Meir Medical Center, Kfar-Saba and Sackler Faculty of Medicine, Tel-Aviv, Israel, 24Department of Medicine, Roskilde Hospital, University of Copenhagen, Copenhagen, Denmark, 25Nefrovisie Renine, Dutch Renal Registry, Leiden, The Netherlands, 26Nephrology Department, Nicosia General Hospital, Nicosia, Cyprus, 27Department of Internal Medicine, Tbilisi State Medical University, Tbilisi, Georgia, 28URDS, Kiev, Ukraine, 29Austrian Dialysis and Transplant Registry, Rohr, Austria, 30REIN Registry, Agence de la Biomédecine, Paris, France, 31Department of Nephrology, Clinical Centre of Serbia, Belgrade University, Belgrade, Serbia, 32General University Hospital and 1st Medical Faculty, Department of Medicine, Charles University, Prague – Strahov, Czech Republic, 33Portuguese Society of Nephrology, Nephrology Department, University Hospital of Coimbra, Coimbra, Portugal, 34Unidad de Información Sobre Pacientes Renales de la Comunidad Autónoma del País Vasco (UNIPAR), Basque Country, Spain, 35Registro Español de Enfermos Renales (REER), Organización Nacional de Trasplantes, Madrid, Spain, 36Scottish Renal Registry, Meridian Court, Glasgow, Scotland, 37Department of Internal Medicine, Tartu University, Tartu, Estonia, 38 Division of Nephrology, Landspitali - National University Hospital of Iceland, Reykjavik, Iceland, 39Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland, 40Servicio de Nefrología, Hospital Universitario Valdecilla, Santander, Cantabria, Spain, 41Clinic for Hemodialysis, Clinical Center, University of Sarajevo, Sarajevo, Bosnia and Herzegovina, 42Polish Renal Registry, Department of Nephrology, Transplantology and Internal Medicine, Medical University, Gdansk, Poland, 43Registro de Enfermos Renales de la Región de Murcia, Servicio de Epidemiología, Consejería de Sanidad, IMIB-Arrixaca, Murcia, Spain, 44Slovak Medical University, Bratislava, Slovakia, 45Department of Internal Medicine, Ryhov County Hospital, Jönköping, Sweden, 46 Swedish Renal Registry, Jönköping, Sweden, 47Service of Nephrology, Dialysis and Transplant, University Hospital Center, Tirana, Albania, 48Division of Nephrology, Department of Medicine, Medical School, Akdeniz University, Antalya, Turkey, 49Registro de Enfermos Renales en Tratamiento Sustitutivo de Castilla-La Mancha, Hospital Virgen de la Salud, Castilla-La Mancha, Spain, 50Norwegian Renal Registry, Renal Unit, Department for Transplant Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway, 51Dialysis Clinic, “Alexandrovska” University Hospital, Sofia Medical University, Sofia, Bulgaria, 52Department of Nephrology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania, 53Lithuanian Nephrology, Dialysis and Transplantation Association, Nephrological Clinic, Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Kaunas, Lithuania, 54Division of Nephrology, Ambroise Paré University Hospital, APHP, University of Paris Ouest-Versailles-St-Quentin-en-Yvelines (UVSQ), Boulogne-Billancourt/Paris, France, 55Institut National de la Santé et de la Recherche Médicale (INSERM) U1018, CESP, Team 5, Villejuif, France, and 56Division of Nephrology, University Clinic, University of Würzburg, Würzburg, Germany Correspondence to: Anneke Kramer; E-mail: a.kramer@amc.uva.nl CLINICAL KIDNEY JOURNAL A summary of the 2013 ERA-EDTA Registry Annual Report | 459 Abstract Background: This article provides a summary of the 2013 European Renal Association–European Dialysis and Transplant Association (ERA-EDTA) Registry Annual Report (available at http://www.era-edta-reg.org), with a focus on patients with diabetes mellitus (DM) as the cause of end-stage renal disease (ESRD). Methods: In 2015, the ERA-EDTA Registry received data on renal replacement therapy (RRT) for ESRD from 49 national or regional renal registries in 34 countries in Europe and bordering the Mediterranean Sea. Individual patient data were provided by 31 registries, while 18 registries provided aggregated data. The total population covered by the participating registries comprised 650 million people. Results: In total, 72 933 patients started RRT for ESRD within the countries and regions reporting to the ERA-EDTA Registry, resulting in an overall incidence of 112 per million population (pmp). The overall prevalence on 31 December 2013 was 738 pmp (n = 478 990). Patients with DM as the cause of ESRD comprised 24% of the incident RRT patients (26 pmp) and 17% of the prevalent RRT patients (122 pmp). When compared with the USA, the incidence of patients starting RRT pmp secondary to DM in Europe was five times lower and the incidence of RRT due to other causes of ESRD was two times lower. Overall, 19 426 kidney transplants were performed (30 pmp). The 5-year adjusted survival for all RRT patients was 60.9% [95% confidence interval (CI) 60.5–61.3] and 50.6% (95% CI 49.9–51.2) for patients with DM as the cause of ESRD. Key words: end-stage renal disease, incidence, prevalence, renal replacement therapy, survival Introduction population. Time trends of the incidence rates were analysed using Joinpoint regression, with the trends presented as annual The European Renal Association–European Dialysis and Trans- percentage change (APC) [2, 3]. plant Association (ERA-EDTA) Registry collects data on renal Patient survival on RRT, on dialysis and following kidney trans- replacement therapy (RRT) for end-stage renal disease (ESRD) plantation was analysed using data from renal registries providing via national and regional renal registries in Europe and from individual patient data for the period 2004–13. A detailed descrip- countries bordering the Mediterranean Sea. Each year an annual tion of the survival methods is given in the Appendix. report is produced, presenting an overview of the incidence and Patients were included in the DM subgroup if they were prevalence of RRT, kidney transplant activity and the survival of registered as having DM type 1 or type 2 as the cause of ESRD patients on RRT in Europe. With this article, we aim to provide a (ERA-EDTA primary renal disease 1995 codes 80 or 81 or ERA- summary of the 2013 Annual Report of the ERA-EDTA Registry [1]. EDTA primary renal disease 2012 codes 2316, 2328, 2337 or 2344 Both the Annual Report and slides summarizing the Annual Report are available at http://www.era-edta-reg.org. This article specifically focuses on the most common cause of ESRD in the Western world: diabetes mellitus (DM). Methods In 2015, the ERA-EDTA Registry received 2013 data from 49 national and regional renal registries in 34 countries in Europe and those bordering the Mediterranean Sea. The majority of renal registries (31 of 49) contributed individual patient data, whereas the other 18 renal registries contributed aggregated data (Figure 1). While a standard Microsoft Excel template was used for the collection of aggregated data, the individual patient data were received in different formats, including SPSS, Microsoft Excel and SAS. Extensive data checking was performed and the data were converted to a standard format in order to be stored in a relational database. After data analysis, the results were checked by the participating renal registries. All registry-specific results in the ERA-EDTA Registry Annual Report were approved by the registries before publication. Mid-year population data for the contributing countries/ regions were received from Eurostat (http://ec.europa.eu/eurostat), the national bureau of statistics or the renal registry. The incidence of RRT was defined as the number of patients starting RRT in one year (2013) and the prevalence of RRT as the number of patients alive and receiving RRT on 31 December Fig. 1. Renal registries from countries and regions in Europe and bordering the 2013. Incidence and prevalence per million population ( pmp) Mediterranean Sea that contributed individual patient data or aggregated data were calculated by dividing the observed count by the mid-year to the ERA-EDTA Registry for 2013. CLINICAL KIDNEY JOURNAL 460 | A. Kramer et al. [1]). As information on DM as comorbidity is not routinely col- distribution (20% DM, 17% hypertension/renal vascular disease, lected by the ERA-EDTA Registry, this article only focuses on 15% glomerulonephritis and 48% other causes of ESRD). Trans- DM as the cause of ESRD. plantation survival probabilities were adjusted for the following values: age 45 years, 60% men, 10% DM, 8% hypertension/renal vascular disease, 28% glomerulonephritis and 54% other causes Statistical methods of ESRD. For the adjusted survival probabilities of the DM sub- group, the corresponding fixed values were used with the excep- Within this article, patient survival on RRT and following kidney tion of the cause of ESRD distribution. transplantation was analysed using the Kaplan–Meier method and Cox proportional hazards regression. For dialysis patients, kidney transplantation is an event that competes with death. Results Therefore, we used the cumulative incidence competing risk For the majority of renal registries contributing data to the ERA- method for the estimation of the unadjusted cause-specific EDTA Registry, the coverage of the population was 100%, with the death probabilities, and the Fine and Gray method for the ad- exception of Croatia (80%), Latvia (80%), Serbia (94%), Switzerland justed cause-specific death probabilities [7]. For the calculation (94%), Spain (95%), Poland (95%), Georgia (96%), Bulgaria (97%), of patient survival on RRT and on dialysis, the date of RRT initi- Czech Republic (98%) and Romania (99%). The total population cov- ation was the starting point and death was the event studied. ered by the participating registries comprised 650 million people. Censored observations were recovery of renal function, loss to The proportion of the European population covered by the ERA- follow-up and end of the follow-up period (31 December 2013). EDTA Registry in 2013 was 73.6%. A list of the European countries For analysis of patient survival following kidney transplantation, with available data and those without is provided in the Appendix. the date of the first kidney transplant was defined as the first day of follow-up and death was the event studied. Reasons for cen- Incidence of RRT in 2013 soring were loss to follow-up and end of the follow-up period. RRT and dialysis survival probabilities were adjusted for fixed va- In 2013, a total of 72 933 patients started RRT for ESRD in all the lues for age (60 years), gender (60% men) and the cause of ESRD registries reporting to the ERA-EDTA Registry, resulting in an Fig. 2. Unadjusted incidence of RRT pmp at Day 1 in 2013 by cause of ESRD. Data are from renal registries providing individual patient data (left panel) and from renal registries providing aggregated data (right panel). Data for Bulgaria, the Czech Republic, Lithuania, Slovakia and Switzerland only include dialysis patients. Registries from Dutch- and French-speaking Belgium, the Spanish regions of Cantabria, Castile and León and Castile-La Mancha and the UK (England, Northern Ireland and Wales) do not report on patients <20 years of age. CLINICAL KIDNEY JOURNAL A summary of the 2013 ERA-EDTA Registry Annual Report | 461 Table 1. Unadjusted incidence of RRT pmp for ESRD at Day 91 by established modality in 2013 for countries/regions providing individual patient data and for countries providing aggregated data All ( pmp) HD ( pmp) PD ( pmp) Tx ( pmp) Other ( pmp) Countries/regions providing individual patient data Austriaa 132.1 113.0 13.5 5.6 0 Belgium Dutch-speakingb 168.4 146.2 18.4 3.8 0 French-speakingb 164.9 140.2 19.5 5.3 0 Bosnia and Herzegovina 110.0 106.3 3.7 0 0 Denmark 109.7 66.1 34.4 8.8 0.4 Estonia 59.9 44.0 12.1 3.8 0 Finland 85.7 57.5 27.4 0.7 0 France 145.9 121.3 17.5 6.5 0.6 Greece 194.4 179.9 13.9 0.5 0 Iceland 74.1 30.9 34.0 9.3 0 Norway 96.1 59.5 22.0 14.6 0 Romania 130.5 122.0 6.9 1.5 0 Serbia 136.9 117.0 17.2 2.7 0 Slovenia 114.6 101.5 11.2 1.9 0 Spain Andalusia 122.2 95.7 21.1 5.4 0 Aragon 125.1 95.9 26.2 3.0 0 Asturiasa 149.2 100.5 45.6 3.1 0 Basque country 114.6 71.8 32.2 10.6 0 Cantabriab 83.2 54.3 22.1 6.8 0 Castile and Leónb 106.5 85.0 18.3 3.2 0 Castile-La Manchab 103.6 76.7 23.5 3.4 0 Cataloniaa 139.3 106.6 20.0 12.8 0 Community of Madrid 117.3 92.4 17.4 7.5 0 Extremaduraa 119.6 102.1 17.5 0.0 0 Galicia 139.8 99.8 31.6 8.3 0 Region of Murcia 103.9 78.8 23.8 1.4 0 Valencia Region 130.0 99.9 28.6 1.6 0 Sweden 104.2 57.5 37.7 9.0 0 The Netherlands 108.4 73.8 17.7 16.8 0 UK Englanda,b 103.3 71.1 21.1 11.1 0 Northern Irelanda,b 86.4 59.9 16.6 9.8 0 Scotland 91.2 69.3 14.3 7.7 0 Walesa,b 103.7 75.6 19.2 8.9 0 All countries 125.8 99.1 19.1 7.3 0.2 Countries providing aggregated patient data Albania 59.2 53.6 4.8 0.7 0 Bulgariac 132.3 128.9 3.4 0 Croatia 133.3 123.1 9.0 1.2 0 Cyprus 175.4 145.0 24.6 5.8 0 Czech Republicc 139.3 130.5 8.8 0 Georgia 148.6 139.3 5.8 0.2 3.3 Israel 171.7 146.9 16.3 8.6 0 Latvia 70.6 61.2 8.7 0.6 0 Lithuaniac 106.3 99.6 6.7 0 Montenegro 22.6 14.5 0.0 8.1 0 Portugald 218.9 198.8 19.3 0.9 0 Slovakiac 132.4 128.6 3.9 0 All countries 148.7 136.6 10.2 1.7 0.2 The category HD also includes haemofiltration and haemodiafiltration. When cells are left empty, the data are unavailable. HD: haemodialysis, PD: peritoneal dialysis, Tx: kidney transplant. a The incidence at Day 91 is based on patients who started RRT in the first 9 months of 2013. b Patients <20 years of age are not reported. c Data include dialysis patients only. d Only pre-emptive transplantations (at Day 1) are included. overall incidence of 112 pmp (Figure 2). For countries/regions providing aggregated data (right panel). The lowest incidence providing individual patient data (left panel), the overall inci- rates were found in Montenegro (27 pmp), Ukraine (30 pmp) and dence at Day 1 was 135 pmp, while it was 98 pmp for countries Russia (50 pmp), whereas the highest rates were observed in CLINICAL KIDNEY JOURNAL 462 | A. Kramer et al. Greece (216 pmp) and both parts of Belgium (Dutch-speaking providing aggregated data showed a greater difference in the part: 187 pmp, French-speaking part: 183 pmp). Figure 2 also incidence of RRT secondary to DM, ranging from 5 pmp in shows the contribution of DM as the cause of ESRD to the inci- Ukraine to 83 pmp in Israel. In general, countries/regions with a dence of RRT. Overall, patients who had DM as the cause of high overall incidence of RRT also had a high incidence of RRT ESRD comprised 24% of the incident patients (26 pmp). For 48% for ESRD secondary to DM. of those patients, the type of DM was unknown (12 pmp), Table 1 shows the unadjusted incidence of RRT pmp on Day 91 while 12% (3 pmp) had DM type 1 and 40% (10 pmp) had DM after the onset of RRT by established treatment modality (haemo- type 2. Among countries/regions whose registries provide dialysis, peritoneal dialysis and kidney transplantation). Overall, individual patient data, the incidence of RRT for ESRD secondary most patients were treated with haemodialysis (99 pmp in renal to DM ranged between 12 pmp in Iceland and 58 pmp in Greece. registries providing individual patient data and 137 pmp in those However, in countries with a high proportion of patients with an providing aggregated data), whereas the incidence of peritoneal unknown or missing cause of ESRD, the proportion of patients dialysis was much lower (19 and 10 pmp, respectively). The inci- with DM as the cause of ESRD may be underestimated, as DM dence of kidney transplantation on Day 91 was highest in The may be the cause of ESRD in some of these patients. For this Netherlands (17 pmp) and Norway (15 pmp), whereas it was low- reason, we also report the incidence of RRT for ESRD due to est in Bosnia and Herzegovina and the Spanish region of Extre- unknown or missing causes of ESRD, which varied widely madura (0 pmp in both cases). Table 2 presents the percentages between 0 pmp in Estonia and 73 pmp in Greece. Countries of established treatment modalities on Day 91 after the start of Table 2. Percentages of established RRT modalities at Day 91, unadjusted, by DM as the cause of ESRD, for countries/regions providing individual patient data Unknown/missing cause All DM Other causes of ESRD of ESRD HD PD Tx Other HD PD Tx Other HD PD Tx Other HD PD Tx Other Austriaa 86 10 4 0 89 9 2 0 84 11 5 0 88 8 4 0 Belgium Dutch-speakingb 87 11 2 0 92 7 1 0 85 13 3 0 93 6 1 0 French-speakingb 85 12 3 0 90 10 0 0 83 12 4 0 87 9 4 0 Bosnia and Herzegovina 97 3 0 0 97 3 0 0 96 4 0 0 97 3 0 0 Denmark 60 31 8 0 67 30 3 0 60 28 12 0 55 41 4 1 Estonia 73 20 6 0 56 38 6 0 78 16 6 0 0 0 0 0 Finland 67 32 1 0 66 34 0 0 66 33 2 0 75 25 0 0 France 83 12 4 0 88 10 2 0 82 12 5 0 82 14 4 0 Greece 93 7 0 0 91 9 0 0 93 7 0 0 93 6 0 0 Iceland 42 46 13 0 50 25 25 0 44 44 11 0 0 100 0 0 Norway 62 23 15 0 69 17 14 0 60 24 16 0 79 21 0 0 Romania 94 5 1 0 94 5 0 0 93 5 2 0 94 6 0 0 Serbia 85 13 2 0 78 20 1 0 89 9 2 0 82 17 1 0 Slovenia 89 10 2 0 89 11 0 0 85 12 3 0 98 2 0 0 Spain Andalusia 78 17 4 0 83 15 2 0 74 21 5 0 84 12 5 0 Aragon 77 21 2 0 81 17 2 0 71 26 3 0 87 13 0 0 Asturiasa 67 31 2 0 45 55 0 0 71 28 1 0 90 0 10 0 Basque country 63 28 9 0 72 26 2 0 65 25 10 0 44 42 14 0 Cantabriab 65 27 8 0 77 8 15 0 61 33 6 0 0 0 0 0 Castile and Leónb 80 17 3 0 88 11 1 0 76 21 4 0 80 16 4 0 Castile-La Manchab 74 23 3 0 81 16 4 0 70 26 4 0 78 22 0 0 Cataloniaa 76 14 9 0 82 16 2 0 73 14 13 0 78 14 8 0 Community of Madrid 79 15 6 0 83 15 2 0 74 16 9 0 86 10 4 0 Extremaduraa 85 15 0 0 82 18 0 0 85 15 0 0 90 9 0 1 Galicia 71 23 6 0 78 22 0 0 63 27 10 0 82 14 3 0 Region of Murciaa 76 23 1 0 85 15 0 0 72 26 2 0 76 24 0 0 Valencia Region 77 22 1 0 82 17 1 0 73 25 2 0 82 18 0 0 Sweden 55 36 9 0 60 36 4 0 53 37 10 0 57 34 8 0 The Netherlands 68 16 16 0 82 15 2 0 75 20 6 0 49 11 40 0 UK Englanda,b 69 20 11 0 76 20 4 0 65 21 14 0 71 20 9 0 Northern Irelanda,b 69 19 11 0 74 23 3 0 69 16 15 0 64 28 8 0 Scotland 76 16 8 0 86 11 3 0 72 17 11 0 78 17 4 0 Walesa,b 73 19 9 0 76 18 6 0 69 20 11 0 80 15 6 0 All countries 77 16 6 0 82 15 2 0 76 17 7 0 77 15 7 0 The category HD also includes haemofiltration and haemodiafiltration. Categories may not add up because of missing values or rounding off. Percentages are row percentages. When cells are left empty, the data are unavailable. HD: haemodialysis, PD: peritoneal dialysis, Tx: kidney transplant. a The incidence at Day 91 is based on patients who started RRT in the first 9 months of 2013. b Patients <20 years of age are not reported. CLINICAL KIDNEY JOURNAL A summary of the 2013 ERA-EDTA Registry Annual Report | 463 Fig. 3. Unadjusted incidence of RRT pmp at Day 1 by cause of ESRD for the USA [4] and Europe. Data for Europe were based on those renal registries that had individual patient data available from 2004, including Austria, Belgium (Dutch-speaking and French-speaking), Denmark, Finland, Greece, Iceland, Norway, Spain (Andalusia, Aragon, Asturias, Basque country, Cantabria, Castile and León, Castile-La Mancha, Catalonia and Valencia Region), Sweden, The Netherlands and UK (all countries). Fig. 4. Unadjusted prevalence of RRT pmp on 31 December 2013 by cause of ESRD. Data are from renal registries providing individual patient data (left panel) and from renal registries providing aggregated data (right panel). Data for Israel, Slovakia and Switzerland only include dialysis patients. For Romania, the overall prevalence of RRT is underestimated by ∼3% due to an estimated 30% underreporting of patients living on a functioning graft. Registries from Dutch- and French-speaking Belgium, the Spanish regions of Cantabria, Castile and León and Castile-La Mancha and the UK (England, Northern Ireland and Wales) do not report on patients <20 years of age. CLINICAL KIDNEY JOURNAL 464 | A. Kramer et al. Table 3. Unadjusted prevalence of RRT pmp for ESRD on 31 December 2013 by treatment modality for countries/regions providing individual patient data and for countries providing aggregated data All ( pmp) HD ( pmp) PD ( pmp) Tx ( pmp) Other ( pmp) Countries/regions providing individual patient data Austria 1053.7 471.3 49.8 532.4 0.2 Belgium Dutch-speakinga 1223.1 648.7 56.8 517.6 0 French-speakinga 1269.9 677.6 57.5 530.6 4.2 Bosnia and Herzegovina 746.9 666.5 24.2 56.2 0 Denmark 876.9 354.1 95.0 424.6 3.2 Estonia 572.1 192.7 33.4 346.0 0 Finland 825.9 269.2 65.8 490.9 0 France 1175.1 601.1 44.4 522.1 7.5 Greece 1172.1 871.8 61.3 239.0 0 Iceland 685.7 148.3 77.2 460.2 0 Norway 900.5 212.8 39.0 648.7 0 Romaniab 816.9 676.7 75.8 64.1 0.3 Serbia 839.1 648.2 69.9 120.4 0.6 Slovenia 1008.3 654.9 25.2 328.2 0 Spain Andalusia 1107.7 493.5 46.4 567.9 0 Aragon 1131.2 416.5 53.2 661.5 0 Asturias 1131.3 402.7 105.8 622.8 0 Basque country 1175.4 373.8 90.2 711.3 0 Cantabriaa 998.5 336.2 59.4 602.9 0 Castile and Leóna 1123.6 484.2 73.8 565.6 0 Castile-La Manchaa 1025.5 390.0 59.0 575.6 1.0 Catalonia 1262.2 532.2 53.4 676.6 0 Community of Madrid 999.3 388.7 54.3 556.2 0 Extremadura 1081.5 531.7 66.1 482.8 0.9 Galicia 1220.9 537.6 101.3 581.9 0 Region of Murcia 1200.4 609.4 63.9 527.2 0 Valencia Region 1232.5 651.4 77.4 502.0 1.8 Sweden 939.5 313.2 86.8 539.5 0.1 The Netherlands 945.4 332.0 55.2 558.2 0 UK Englanda 890.4 372.9 59.0 458.5 0 Northern Irelanda 846.0 354.2 44.3 447.6 0 Scotland 866.0 350.4 43.4 471.9 0.4 Walesa 886.0 348.1 57.4 480.5 0 All countries 1019.8 501.0 57.5 459.3 2.0 Countries providing aggregated patient data Albania 340.5 257.1 18.0 65.4 0 Bulgaria 540.9 449.4 22.3 69.3 0 Croatia 799.5 583.3 37.1 159.9 19.3 Czech Republic 1033.5 562.3 50.3 420.9 0 Georgia 385.2 324.1 20.8 38.5 1.9 Israelc 734.7 692.1 42.4 0.1 Latvia 600.3 221.8 53.7 324.8 0 Lithuania 719.0 475.4 15.8 227.8 0 Montenegro 304.8 133.9 4.8 166.1 0 Poland 822.4 513.4 27.9 281.1 0 Portugal 1749.3 1046.7 69.8 632.8 0 Russia 241.4 179.8 13.8 47.8 0 Slovakiac 609.0 592.9 16.1 Spain (18 of 19 regions) 1125.8 482.1 62.1 579.9 1.8 Switzerlandc 381.6 349.5 32.0 0.1 Turkey 870.2 687.1 59.2 123.9 0 Ukraine 159.0 117.6 21.3 20.1 0 All countries 589.6 392.4 33.4 163.3 0.4 The category HD also includes haemofiltration and haemodiafiltration. When cells are left empty, the data are unavailable. HD: haemodialysis, PD: peritoneal dialysis, Tx: kidney transplant. a Patients <20 years of age are not reported. b The overall prevalence of RRT is underestimated by ∼3% due to an estimated 30% underreporting of patients living with a functioning graft. c Data include dialysis patients only. CLINICAL KIDNEY JOURNAL A summary of the 2013 ERA-EDTA Registry Annual Report | 465 RRT for all patients, for patients with DM, for patients with other analyses revealed that in Europe, the incidence of patients start- causes of ESRD and for patients with an unknown cause of ESRD. ing RRT for ESRD secondary to DM decreased from 2007, although Patients with DM were more often treated with any type of dialy- this was not statistically significant {2004–7: APC 1.9 [95% sis on Day 91 after the start of RRT than patients with other confidence interval (CI) −1.1–+5.1], 2007–13: APC −0.9 [95% CI causes of ESRD (98 versus 93%), while they were less often trans- −1.9–0.2]}. In the USA, the reported incidence of RRT for ESRD sec- planted (2 versus 7%). ondary to DM remained stable during the last decade [APC 0.2 (95% CI −0.2–0.5)]. Trends in the incidence of RRT over time in the USA and Europe Prevalence of RRT on 31 December 2013 Figure 3 shows the trend in the incidence of RRT over the last 10 Figure 4 shows the unadjusted prevalence of RRT pmp on 31 years, by cause of ESRD, in both Europe and the USA [data ex- December 2013, by cause of ESRD. Overall, 477 186 patients tracted from the US Renal Data System (USRDS) Annual Report were receiving RRT on 31 December 2013, resulting in an [4]]. When compared with the USA, the incidence of patients overall prevalence of 738 pmp The prevalence was highest in starting RRT for ESRD secondary to DM is almost five times Portugal (1749 pmp), French-speaking Belgium (1270 pmp) and lower in Europe and the incidence of RRT for ESRD due to other the Spanish region of Catalonia (1262 pmp), whereas it was low- causes of ESRD is at least two times lower. Joinpoint regression est in Ukraine (159 pmp), Russia (241 pmp) and Montenegro Table 4. Percentages of RRT modalities among prevalent patients on 31 December 2013, unadjusted, by DM as the cause of ESRD for countries/ regions providing individual patient data Unknown/missing cause All DM Other causes of ESRD of ESRD HD PD Tx Other HD PD Tx Other HD PD Tx Other HD PD Tx Other Austria 45 5 51 0 60 4 36 0 40 5 55 0 45 5 50 0 Belgium Dutch-speakinga 53 5 42 0 71 4 25 0 48 5 47 0 57 2 41 0 French-speakinga 53 5 42 0 71 5 23 0 50 4 45 0 44 5 51 0 Bosnia and Herzegovina 89 3 8 0 92 5 3 0 89 3 8 0 87 2 11 0 Denmark 40 11 48 0 54 13 33 0 36 9 55 0 44 15 41 0 Estonia 34 6 60 0 26 10 64 0 36 5 60 0 0 0 0 0 Finland 33 8 59 0 40 10 50 0 26 6 67 0 56 12 32 0 France 51 4 44 1 73 5 22 0 47 3 49 1 51 5 43 1 Greece 74 5 20 0 89 7 4 0 68 5 27 0 77 5 19 0 Iceland 22 11 67 0 29 13 58 0 20 10 70 0 29 29 43 0 Norway 24 4 72 0 34 4 63 0 22 4 74 0 42 5 54 0 Romaniab 83 9 8 0 86 11 3 0 81 9 9 0 84 9 7 0 Serbia 77 8 14 0 77 16 7 0 78 7 15 0 73 9 17 0 Slovenia 65 3 33 0 86 3 11 0 59 2 39 0 70 2 27 0 Spain Andalusia 45 4 51 0 63 6 31 0 39 4 57 0 50 3 47 0 Aragon 37 5 58 0 57 6 37 0 36 4 60 0 24 4 72 0 Asturias 36 9 55 0 46 18 36 0 32 8 60 0 39 6 55 0 Basque country 32 8 61 0 56 12 32 0 27 7 67 0 38 11 52 0 Cantabriaa 34 6 60 0 50 6 44 0 31 6 63 0 36 0 64 0 Castile and Leóna 43 7 50 0 60 7 32 0 45 8 47 0 29 3 68 0 Castile-La Manchaa 38 6 56 0 57 7 35 0 33 6 61 0 39 4 57 0 Catalonia 42 4 54 0 63 6 31 0 34 3 62 0 51 5 43 0 Community of Madrid 39 5 56 0 57 7 36 0 33 6 61 0 43 3 54 0 Extremadura 49 6 45 0 76 7 17 0 43 7 50 0 46 4 50 0 Galicia 44 8 48 0 63 11 26 0 37 8 56 0 49 9 42 0 Region of Murcia 51 5 44 0 71 6 23 0 46 6 48 0 52 4 44 0 Valencia Region 53 6 41 0 71 7 22 0 47 6 46 0 59 6 35 0 Sweden 33 9 57 0 45 12 43 0 29 8 63 0 43 12 45 0 The Netherlands 35 6 59 0 55 7 38 0 33 6 62 0 32 5 63 0 UK Englanda 42 7 51 0 59 9 32 0 37 6 58 0 45 8 47 0 Northern Irelanda 42 5 53 0 66 6 28 0 36 5 59 0 46 9 45 0 Scotland 40 5 54 0 59 6 35 0 35 5 60 0 48 5 47 0 Walesa 39 6 54 0 55 7 39 0 34 7 60 0 46 5 49 0 All countries 49 6 45 0 66 8 27 0 45 5 50 0 51 6 41 0 The category HD also includes haemofiltration and haemodiafiltration. When cells are left empty, the data are unavailable. HD: haemodialysis, PD: peritoneal dialysis, Tx: kidney transplant. a Patients <20 years of age are not reported. b The overall prevalence of RRT is underestimated by ∼3% due to an estimated 30% underreporting of patients living with a functioning graft. CLINICAL KIDNEY JOURNAL 466 | A. Kramer et al. (305 pmp). Patients with DM as the cause of ESRD comprised 17% Kidney transplants performed in 2013 of the prevalent patients (122 pmp). For 54% of these patients, the Figure 5 shows the kidney transplant rate in 2013 for countries/re- type of DM was unknown (66 pmp), while 14% (18 pmp) had DM gions whose registries provide individual patient data and for type 1 and 31% (38 pmp) had DM type 2. In countries/regions countries whose registries provide aggregated patient data, by with registries providing individual patient data, the overall donor type. Overall, 19 426 kidney transplantations were per- prevalence of RRT for ESRD secondary to DM was 159 pmp, ran- formed (30 pmp), of which 6002 (9 pmp) transplants came from ging between 74 pmp in Iceland and 219 pmp in Greece. Tables 3 living donors, 13 207 (20 pmp) from deceased donors and 217 and 4 present the prevalence by treatment modality (haemodi- (0.3 pmp) from an unknown donor source. The three Spanish alysis, peritoneal dialysis and kidney transplantation) on 31 De- regions—Cantabria (104 pmp), Basque country (75 pmp) and cember 2013 ( pmp and as percentage). In countries/regions Catalonia (71 pmp)—had the highest kidney transplant rates, with registries providing individual patient data, most prevalent while Ukraine (3 pmp), Albania (3 pmp) and Russia (7 pmp) patients were receiving haemodialysis, closely followed by those showed the lowest rates. The highest living donor kidney trans- with a functioning graft. In countries with registries providing ag- plant rates were found in The Netherlands (31 pmp), Turkey gregated data, the great majority of the patients were receiving (31 pmp) and Cyprus (27 pmp). haemodialysis. Table 4 shows that in case of patients with DM as the cause of ESRD, only four registries reported ≥50% of pa- Patient survival tients living with a functioning graft. In contrast, for other causes of ESRD, the vast majority of the registries reported that more Survival analyses included data from 22 registries in 11 countries, than half of the patients had a functioning graft. which provided individual patient data for the period of 2004–11. Fig. 5. Kidney transplants pmp performed in 2013, unadjusted. Data are from renal registries providing individual patient data (left panel) and aggregated data (right panel). For Slovakia, data were obtained from the Slovak Centre of Organ Transplantation, and for Spain (18 of 19 regions), from the Organización Nacional de Transplantes. For Romania, the kidney transplantation activity reflects 70% of the total kidney transplantation activity in the country due to an underreporting of pre- emptive kidney transplantations. Registries from Dutch- and French-speaking Belgium, the Spanish regions of Cantabria, Castile and León and Castile-La Mancha and the UK (England, Northern Ireland and Wales) do not report on patients <20 years of age. CLINICAL KIDNEY JOURNAL A summary of the 2013 ERA-EDTA Registry Annual Report | 467 Table 5 shows the unadjusted and adjusted survival probabilities years, 686 (60.2 pmarp) were ages 10–14 years and 1217 (105.9 for patients starting RRT or dialysis or receiving their first kidney pmarp) were ages 15–19 years. transplant between 2004 and 2008. In order to present more re- A more detailed overview of the paediatric RRT data in Europe cent survival data, 1- and 2-year survival probabilities are also can be found at the ESPN/ERA-EDTA Registry website (http:// presented, for patients starting RRT/dialysis or receiving their www.espn-reg.org). first kidney transplant between 2007 and 2011. The survival of pa- tients with DM as the cause of ESRD was worse when compared with the total group of patients starting RRT, dialysis or receiving Discussion a kidney transplant. Two-year survival probabilities were higher for patients starting RRT, dialysis or receiving a kidney transplant This summary of the 2013 ERA-EDTA Registry Annual Report in- between 2007 and 2011 than between 2004 and 2008. cludes data from 49 national and regional renal registries in 34 countries in Europe and bordering the Mediterranean Sea, with a special focus on patients receiving RRT for ESRD secondary to DM. Both the overall incidence of RRT for ESRD and the incidence Paediatric patients of RRT for ESRD secondary to DM were substantially lower in Eur- For children, we performed a separate analysis of the incidence ope than in the USA [4]. However, even in Europe and among and prevalence by age group using data from 25 national or re- countries bordering the Mediterranean Sea, there were notable gional renal registries from 16 countries that provided individual differences in the incidence of RRT for ESRD secondary to DM. paediatric data. In 2012–13, 686 children [7.5 per million age-re- This variation may be explained in part by differences in the lated population ( pmarp)] started RRT. Of these children, 135 (6.0 prevalence of DM within the general population [5], differences pmarp) were <5 years of age at the onset of RRT, 96 (4.2 pmarp) in preventive measures, such as lifestyle advice and the use of re- were ages 5–9 years, 175 (7.7 pmarp) were ages 10–14 years and noprotective medication, and differences in macroeconomic fac- 280 (12.1 pmarp) were ages 15–19 years. On 31 December 2013, tors and nephrology services [6]. It should be noted that this 2529 (55.3 pmarp) children were receiving RRT, of whom 203 (18.0 variation may also be influenced by discrepancies in the propor- pmarp) were <5 years of age, 423 (36.6 pmarp) were ages 5–9 tion of patients coded with a missing or unknown cause of ESRD. Table 5. One-, 2- and 5-year unadjusted and adjusted patient survival probabilities (in %) with 95% confidence interval for all patients and for patients with DM as the cause of ESRD 2004–8 period 2007–11 period 1 year 2 year 5 year 1 year 2 year Patient survival on RRT Unadjusted All 82.1 (81.9–82.3) 71.2 (71.0–71.4) 48.3 (48.2–48.5) 83.5 (83.3–83.7) 73.1 (72.9–73.3) DM 82.3 (81.8–82.7) 68.8 (68.4–69.2) 40.2 (39.9–40.4) 83.9 (83.5–84.3) 71.1 (70.7–71.5) Adjusteda All 89.2 (89.0–89.3) 81.4 (81.1–81.7) 60.9 (60.5–61.3) 90.0 (89.8–90.2) 82.7 (82.5–83.0) DM 87.8 (87.4–88.1) 77.3 (76.8–77.8) 50.6 (49.9–51.2) 89.0 (88.7–89.4) 79.4 (78.9–79.9) Patient survival on dialysis (with kidney transplantation as competing event) Unadjusted All 81.6 (81.4–81.8) 70.5 (70.3–70.8) 48.1 (47.9–48.4) 82.8 (82.6–83.0) 72.1 (71.9–72.3) DM 82.0 (81.6–82.4) 68.6 (68.2–69.0) 40.6 (40.1–41.1) 83.5 (83.2–83.9) 70.6 (70.1–71.1) Adjusteda All 89.4 (89.3–89.6) 81.9 (81.7–82.1) 62.4 (62.2–62.8) 89.9 (90.0–89.8) 82.6 (82.8–82.4) DM 87.3 (87.1–87.5) 78.5 (78.2–78.8) 56.6 (56.2–57.0) 88.5 (88.6–88.3) 80.2 (80.5–80.0) Patient survival after first kidney transplantation (deceased donor) Unadjusted All 95.7 (95.4–96.0) 93.7 (93.4–94.1) 87.1 (86.7–87.5) 96.0 (95.7–96.2) 94.0 (93.6–94.3) DM 93.9 (93.0–94.7) 91.3 (90.3–92.2) 81.6 (80.3–82.7) 94.8 (94.0–95.4) 92.2 (91.3–93.0) Adjusteda All 97.4 (97.2–97.6) 96.1 (95.9–96.4) 91.8 (91.4–92.2) 97.6 (97.4–97.8) 96.4 (96.1–96.6) DM 95.8 (95.1–96.4) 93.8 (93.1–94.6) 86.5 (85.4–87.7) 96.5 (95.9–97.0) 94.7 (94.0–95.4) Patient survival after first kidney transplantation (living donor) Unadjusted All 98.3 (98.0–98.6) 97.4 (97.0–97.8) 94.3 (93.7–94.8) 98.6 (98.3–98.8) 97.6 (97.3–97.9) DM 96.3 (94.2–97.6) 93.4 (90.9–95.2) 85.3 (82.3–87.8) 96.8 (95.3–97.9) 94.9 (93.0–96.2) Adjusteda All 98.7 (98.4–99.0) 98.1 (97.7–98.4) 95.6 (95.0–96.1) 99.1 (98.9–99.3) 98.4 (98.2–98.7) DM 97.5 (96.4–98.7) 95.6 (94.0–97.2) 89.8 (87.5–92.3) 98.1 (97.3–98.9) 96.9 (95.8–98.0) Based on data from Austria, Belgium (Dutch-speaking and French-speaking), Denmark, Finland, Greece, Iceland, Norway, Spain (Andalusia, Aragon, Asturias, Basque country, Cantabria, Castile and León, Castile-La Mancha, Catalonia, Extremadura and Valencia Region), Sweden, The Netherlands and UK (all countries). a Adjusted survival probabilities were adjusted for age, gender and cause of ESRD. For the adjusted survival probabilities of the DM subgroup, only age and gender were taken into account. CLINICAL KIDNEY JOURNAL 468 | A. Kramer et al. Nevertheless, in view of the ongoing epidemic of DM in Western Spanish Society of Nephrology (SEN); Sweden: K.G. Prütz, societies [5], it is remarkable that both in Europe and in the USA, M. Stendahl, M. Evans, S. Schön, L. Bäckman and M. Segelmark; the rise in the incidence of RRT for ESRD secondary to DM ap- Switzerland: P. Ambühl and R. Winzeler; The Netherlands: pears to have subsided. M. Hemmelder and A. Hemke; Turkey: G. Süleymanlar, Although patients receiving RRT for ESRD secondary to DM N. Seyahi and M.R. Maltiparmak; Ukraine: M. Kolesnyk and were less likely to receive a kidney transplant and had worse S. Nikolaenko; UK, England/Northern Ireland/Wales: all the staff survival compared with the overall group, their survival seems of the UK Renal Registry and of the renal units submitting data; to be improving with time. UK, Scotland: all of the Scottish renal units. In conclusion, we have shown encouraging results for pa- tients receiving RRT for ESRD secondary to DM. This suggests that advances in health care have been effective with regard to ERA-EDTA registry committee members the prevention and management of ESRD secondary to DM. A. Wię cek (ERA-EDTA President); C. Wanner, Germany (Chair- man); F.J. Caskey, UK; F. Collart, Belgium; C. Couchoud, France; D. Fouque, France; J.W. Groothoff, The Netherlands; J.G. Acknowledgements Heaf, Denmark; P. Ravani, Italy; I. Rychlik, Czech Republic; The ERA-EDTA Registry would like to thank the patients and staff F. Schaefer, Germany; S. Schön, Sweden. of all the dialysis and transplant units who have contributed data via their national and regional renal registries. In addition, we would like to thank the persons and organizations listed in the ERA-EDTA registry office staff ‘Affiliated registries’ for their contribution to the work of K.J. Jager (Managing Director), M. Bonthuis (for paediatric the ERA-EDTA Registry. The ERA-EDTA Registry is funded by section), R. Cornet, F.W. Dekker, G. Guggenheim, A. Kramer, the ERA-EDTA. This article was written by Anneke Kramer et al. M. Noordzij, M. Pippias, V.S. Stel and A.J. Weerstra. on behalf of the ERA-EDTA Registry, which is an official body of the ERA-EDTA, and it was approved by all co-authors. Conflict of interest statement None declared. Affiliated registries Albania: N. Thereska, A. Strakosha and N. Pasko; Austria: (See related article by van den Brand et al. Diabetes mellitus as a R. Kramar; Belgium, Dutch-speaking: B. De Moor, F. Schroven cause of end-stage renal disease in Europe: signs of improve- and J. De Meester; Belgium, French-speaking: J.M. des Grottes ment. Clin Kidney J (2016) 9: 454–456.) and F. Collart; Bosnia-Herzegovina: H. Resić, B. Prnjavorac and N. Petković; Bulgaria: E. Vazelov and V. Mushekov; Croatia: I. Bubić, S. Rač ki and N. Janković; Cyprus: K. Ioannou and all of Appendix the renal units providing data; Czech Republic: I. Rychlík, Coverage of the European population by the J. Potucek and F. Lopot; Denmark: J.G. Heaf; Estonia: Ü. Pechter, ERA-EDTA registry M. Rosenberg and K. Lilienthal; Finland: P. Finne and C. Grönhagen-Riska; France: M. Lassalle and C. Couchoud; European countries supplying data to the ERA-EDTA Registry Georgia: N. Kantaria and Dialysis Nephrology and Transplant- in 2013: Albania, Austria, Belgium, Bosnia and Herzegovina, ation Union of Georgia; Greece: N. Afentakis; Iceland: Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, R. Palsson; Israel: R. Dichtiar, T. Shohat and E. Golan; Latvia: Finland, France, Georgia, Greece, Iceland, Latvia, Lithuania, H. Cernevskis and V. Kuzema; Lithuania: V. Kuzminskis, I.A. Montenegro, the Netherlands, Norway, Poland, Portugal, Bumblytė and E. Žiginskienė ; Montenegro: M. Ratkovic, D Radu- Romania, Russia, Serbia, Slovakia, Slovenia, Spain, Sweden, novic and S. Ivanovic; Norway: T. Leivestad; Poland: Switzerland, Turkey, Ukraine and the UK. B. Rutkowski, G. Korejwo and P. Jagodziń ski; Portugal: European countries not supplying data to the ERA-EDTA Registry F. Macário, F. Nolasco and R. Filipe; Romania: G. Mircescu, in 2013: Andorra, Armenia, Azerbaijan, Belarus, former Yugoslav L. Garneata and E. Podgoreanu; Russia: B. Bikbov and Republic of Macedonia, Germany, Hungary, Ireland, Italy, Kosovo N. Tomilina; Serbia: working group of the Serbian RRT Registry (under United Nations Security Council Resolution 1244/99), Liech- and all of the Serbian renal units; Slovakia: V. Spustová, tenstein, Luxembourg, Malta, Moldova, Monaco and San Marino. I. Lajdova and M. Karolyova; Slovenia: J. Buturovic-Ponikvar, The coverage of the European population by the ERA-EDTA Regis- J. Gubenšek and M. Arnol; Spain, Andalusia: P. Castro de la try in 2013 was 73.6%. For this calculation, only the proportions Nuez; Spain, Aragon: J.I. Sanchez Miret and J.M. 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