Clinical Kidney Journal, 2020, vol. 13, no. 4, 693–709 doi: 10.1093/ckj/sfaa048 Advance Access Publication Date: 22 June 2020 Original Article ORIGINAL ARTICLE The ERA-EDTA Registry Annual Report 2017: a summary Anneke Kramer 1, Rianne Boenink1, Marlies Noordzij1, Jizzo R. Bosdriesz1, Vianda S. Stel1, Palma Beltrán2, Juan C. Ruiz3, Nurhan Seyahi4, Jordi Comas Farnés5, Maria Stendahl6, Liliana Garneata7, Rebecca Winzeler8, Eliezer Golan9, Frantisek Lopot10, Grzegorz Korejwo11, Marjolein Bonthuis12, Mathilde Lassalle13, Maria F. Slon Roblero14, Viktorija Kuzema15,16,17, Kristine Hommel18, Olivera Stojceva-Taneva19, Anders Asberg20, Reinhard Kramar21, Marc H. Hemmelder22, Johan De Meester23, Evgueniy Vazelov24, Anton Andrusev25,26, Pablo Castro de la Nuez27, Jaakko Helve28,29, Kirill Komissarov30, Anna Casula31, Ángela Magaz32, Carmen Santiuste de Pablos33,34, Ivan Bubic 35,36, Jamie P. Traynor 37, Kyriakos Ioannou38,39, Alma Idrizi40, Runolfur Palsson41,42, Jean-Marin des Grottes43, Viera Spustova44, Miloreta Tolaj-Avdiu45, Faical Jarraya46, Maurizio Nordio47, Edita Ziginskiene48,49, Ziad A. Massy50,51 and Kitty J. Jager1 1 ERA-EDTA Registry, Department of Medical Informatics, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands, 2Public Health Directorate, RERCA Registry, Oviedo, Asturias, Spain, 3Department of Nephrology, Valdecilla Hospital, University of Cantabria, IDIVAL, Santander, Cantabria, Spain, 4Department of Nephrology, Cerrahpasa Medical Faculty, Istanbul University, Cerrahpasa, Istanbul, Turkey, 5Catalan Renal Registry, Catalan Transplant Organization, Health Department, Generalitat of Catalonia, Barcelona, Spain, 6Swedish Renal Registry, Department of Internal Medicine, Jonkoping Regional Hospital, Jonkoping, Sweden, 7Romanian Renal Registry, Department of Internal Medicine and Nephrology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania, 8Institute of Nephrology, Waid and Triemli City Hospital, Zurich, Switzerland, 9Israel Renal Registry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel, 10Department of Medicine, General University Hospital, Prague – Strahov, Czech Republic, 11Department of Nephrology, Gdan  sk Medical University, Gdansk, Poland, 12ESPN/ERA-EDTA Registry, Department of Medical Informatics, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands, Received: 10.3.2020; Editorial decision: 16.3.2020 C The Author(s) 2020. Published by Oxford University Press on behalf of ERA-EDTA. V 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 693 694 | A. Kramer et al. 13 Renal Epidemiology and Information Network Registry, Agence de la biomédecine, Saint-Denis La Plaine, France, 14Complejo Hospitalario de Navarra, Pamplona, Navarra, Spain, 15Department of Nephrology, Riga Stradins Clinical University Hospital, Riga, Latvia, 16Department of Internal Medicine, Riga Stradins University, Riga, Latvia, 17Latvian Nephrology Association, Riga, Latvia, 18Department of Nephrology, Holbæk Sygehus, Holbæk, Denmark, 19Medical Faculty, University “Sts. Cyril and Methodius”, Skopje, Republic of North Macedonia, 20Department of Transplantation Medicine, Oslo University Hospital – Rikshospitalet, Oslo, Norway, 21Austrian Dialysis and Transplant Registry, Rohr, Austria, 22Dutch Renal Registry, Nefrovisie Foundation, Utrecht, The Netherlands, 23Dutch-speaking Belgian Renal Registry (NBVN), Antwerp, Belgium, 24 Dialysis Clinic, “Alexandrovska” University Hospital, Sofia Medical University, Sofia, Bulgaria, 25Chronic Dialysis, Russia & CIS Medical Department, Company “Baxter” AO, Moscow, Russia, 26Renal Replacement Registry, Russian Dialysis Society, Moscow, Russia, 27Information System of the Autonomic Transplant Coordination of Andalucia (SICATA), Seville, Andalucia, Spain, 28Finnish Registry for Kidney Diseases, Helsinki, Finland, 29Abdominal Center, Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland, 30Minsk Scientific and Practical Center of Surgery, Transplantation and Hematology, Minsk, Belarus, 31UK Renal Registry, Bristol, UK, 32Unidad de Información de Pacientes Renales - UNIPAR, Basque Country, Spain, 33Murcia Renal Registry, Department of Epidemiology, Murcia Regional Health Authority, IMIB-Arrixaca, Murcia, Spain, 34CIBER Epidemiologı́a y Salud Pública (CIBERESP), Madrid, Spain, 35Department of Internal Medicine, Faculty of Medicine, University of Rijeka, Rijeka, Croatia, 36Department of Clinical Sciences I, Faculty of Health Sciences, University of Rijeka, Rijeka, Croatia, 37Scottish Renal Registry, Meridian Court, ISD Scotland, Glasgow, UK, 38Cyprus Renal Registry, Nicosia, Cyprus, 39Nephrology Department, American Medical Center, Nicosia, Cyprus, 40Service of Nephrology, UHC “Mother Teresa”, Tirana, Albania, 41 Division of Nephrology, Landspitali–The National University Hospital of Iceland, Reykjavik, Iceland, 42 Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland, 43CHU Tivoli, La Louvière, Belgium, 44Department of Clinical and Experimental Pharmacotherapy, Slovak Medical University, Bratislava, Slovakia, 45Nephrology Department, Clinical University Centre of Kosova, Prishtina, Kosovo, 46 Service de Néphrologie, Faculte de medicine, CHU H Chaker Sfax and LR19ES11, Sfax, Tunisia, 47Division of Nephrology, Dialysis and Transplantation, AULSS2 Treviso, Italy, 48Lithuanian Nephrology, Dialysis and Transplantation Association, Kaunas, Lithuania, 49Nephrology Department, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania, 50Division of Nephrology, Ambroise Paré University Hospital, Boulogne-Billancourt, France and 51Institut National de la Santé et de la Recherche Médicale (INSERM) Unit 1018 , Team 5, Research Centre in Epidemiology and Population Health (CESP), University of Paris Ouest-Versailles-St Quentin-en-Yveline, Villejuif, France Correspondence to: Anneke Kramer; E-mail: a.kramer@amsterdamumc.nl; Twitter handle: @EraEdtaRegistry ABSTRACT Background. This article presents a summary of the 2017 Annual Report of the European Renal Association–European Dialysis and Transplant Association (ERA-EDTA) Registry and describes the epidemiology of renal replacement therapy (RRT) for end-stage renal disease (ESRD) in 37 countries. Methods. The ERA-EDTA Registry received individual patient data on patients undergoing RRT for ESRD in 2017 from 32 national or regional renal registries and aggregated data from 21 registries. The incidence and prevalence of RRT, kidney transplantation activity and survival probabilities of these patients were calculated. Results. In 2017, the ERA-EDTA Registry covered a general population of 694 million people. The incidence of RRT for ESRD was 127 per million population (pmp), ranging from 37 pmp in Ukraine to 252 pmp in Greece. A total of 62% of patients were men, 52% were 65 years of age and 23% had diabetes mellitus as the primary renal disease. The treatment modality at the onset of RRT was haemodialysis for 85% of patients. On 31 December 2017, the prevalence of RRT was 854 pmp, ranging from 210 pmp in Ukraine to 1965 pmp in Portugal. The transplant rate in 2017 was 33 pmp, ranging from 3 pmp in Ukraine to 103 pmp in the Spanish region of Catalonia. For patients commencing RRT during 2008–12, the unadjusted 5-year patient survival probability for all RRT modalities combined was 50.8%. Keywords: dialysis, end-stage renal disease, epidemiology, kidney transplantation, survival analysis ERA-EDTA Registry Annual Report 2017 | 695 Table 1. Incidence of RRT in 2017 at Day 1, by country/region, presented as count (n) and unadjusted rate pmp, the mean and median age at the start of RRT and the number and rate of patients with types 1 and 2 DM as primary renal disease Incidence of RRT in 2017, at Day 1 General population covered All All Mean Median DM DM Country/region by the registry in thousands (n) (pmp) age (years) age (years) (n) (pmp) Albania 2847 255 90 51.2 52.1 51 18 Austria 8773 1134 129 65.7 68.8 308 35 Belarus 9492 952 100 216 23 Belgium, Dutch-speakinga 6543 1194 182 70.6 73.4 255 39 Belgium, French-speakinga 4832 941 195 68.3 70.7 231 48 Bosnia and Herzegovina 3531 381 108 61.9 63.5 114 32 Bulgaria 7050 1195 170 322 46 Croatia 3713 710 191 67.6 69.0 204 55 Cyprus 864 204 236 68.0 69.0 78 90 Czech Republicb 9920 2301 232 Denmark 5821 761 131 63.8 67.5 198 34 Estonia 1317 87 66 57.0 60.3 16 12 Finland 5508 549 100 60.9 64.9 182 33 France 66 865 11 571 173 67.7 70.5 2678 40 Georgia 3726 782 210 60.9 63.3 194 52 Greece 10 755 2712 252 71.3 74.0 675 63 Iceland 343 49 143 62.2 66.3 4 12 Israel 8713 1683 193 65.6 68.4 779 89 Italy (8 of 20 regions) 26 298 3722 140 68.9 71.8 675 25 Kosovo 1688 321 190 62.9 65.0 104 62 Latvia 1547 177 114 60.9 62.0 29 19 Lithuania 2848 341 120 61.7 62.7 50 18 North Macedonia 2022 365 181 62.7 63.0 100 49 Norway 5277 584 111 63.5 66.9 104 20 Polandb 38 430 6550 170 1470 38 Portugal 10 310 2372 230 753 73 Romania 19 000 3559 187 62.3 64.3 456 24 Russiab 142 473 9495 67 55.8 58.0 1680 12 Serbia 6810 678 100 57.4 62.4 200 29 Slovakiab 5437 927 170 62.0 65.0 344 63 Spain (all regions) 46 572 6567 141 63.5 68.1 1572 34 Spain, Andalusia 8409 1107 132 63.6 66.5 270 32 Spain, Aragon 1315 168 128 64.5 68.6 45 34 Spain, Asturias 1034 161 156 67.0 71.1 41 40 Spain, Basque Country 2169 249 115 63.7 67.2 72 33 Spain, Canary Islands 2166 346 160 63.8 66.1 124 57 Spain, Cantabriaa 581 65 112 64.7 67.5 13 22 Spain, Castile and Leóna 2427 296 122 67.3 68.9 75 31 Spain, Castile-La Manchaa 2037 265 130 66.2 68.5 74 36 Spain, Catalonia 7556 1250 165 66.7 70.3 257 34 Spain, Community of Madrid 6507 865 133 65.0 68.0 228 35 Spain, Extremadura 1080 119 110 63.3 65.3 29 27 Spain, Galicia 2707 416 154 65.2 68.0 97 36 Spain, Murcia 1470 202 137 64.9 67.7 49 33 Spain, Navarrea 642 79 123 65.1 68.4 18 28 Sweden 10 058 1165 116 63.8 67.7 284 28 Switzerland 8452 824 97 65.5 68.8 160 19 The Netherlands 15 932 1839 115 64.5 68.1 370 23 Tunisia, Sfax regionb 990 239 242 62.3 64.0 66 67 Turkeyc 80 811 11 837 146 703 9 UK, Englanda,d 55 619 6649 120 61.9 63.9 1656 30 UK, Northern Irelanda 1871 212 113 63.7 67.7 50 27 UK, Scotland 5425 639 118 59.3 61.9 172 32 UK, Walesa 3125 379 121 62.9 66.3 105 34 Ukraine 42 415 1551 37 52.2 55.0 327 8 All countries 694 024 88 453 127 63.4 66.2 17 935 29 When cells are left empty, the data were unavailable and could not be used for the calculation of the summary data. a Patients <20 years of age are not reported. The true incidence counts are therefore slightly higher than the counts reported here. b Data include dialysis patients only. c Data on primary renal disease are available for 1893 dialysis patients (16.0%; total n ¼ 11 837). d The incidence is underestimated by 2% due to one centre not submitting data since 2014. 696 | A. Kramer et al. FIGURE 1: Incidence (pmp) of RRT in 2017, at Day 1, by country/region, unadjusted. The incidence for the Czech Republic, Poland, Russia, Slovakia and Sfax region (Tunisia) only includes patients receiving dialysis. For England (UK), the incidence is underestimated by 2% (Table 1). ERA-EDTA Registry Annual Report 2017 | 697 FIGURE 2: Unadjusted (left panel) and adjusted (right panel) incidence of RRT pmp in 2017, at Day 1, by country/region. Registries providing individual patient data are shown as dark bars and registries providing aggregated data as light bars. Adjustment of incidence was performed by standardizing the rates to the age and sex distri- bution of the 27 European Union (EU27) countries’ population. The incidence for the Czech Republic, Poland, Russia, Slovakia and Sfax region (Tunisia) only includes patients receiving dialysis. For England (UK), the incidence is underestimated by 2% (Table 1). INTRODUCTION Registry’s 2017 Annual Report and presents the most recent data on the epidemiology of renal replacement therapy (RRT) This article is based on the European Renal Association– for end-stage renal disease (ESRD) in Europe. Data for the year European Dialysis and Transplant Association (ERA-EDTA) 2017 were received from 53 national or regional renal registries 698 | A. Kramer et al. FIGURE 3: (A) Sex, (B) age and (C) primary renal disease distribution by type of data provided for incident patients accepted for RRT in 2017, at Day 1. See Appendix A1 for a list of countries and regions providing individual patient data FIGURE 4: Treatment modality distribution, at Day 1, by (A) type of data pro- or aggregated data. vided, (B) age, (C) sex and (D) primary renal disease (DM and non-DM) for inci- dent patients accepted for RRT in 2017. (B–D) Based on the data from registries from 37 countries in Europe and countries bordering the providing individual patient data. See Appendix A1 for a list of countries and Mediterranean Sea [1]. In total, these registries represent a gen- regions providing individual patient data or aggregated data. Tx, kidney eral population of 694 million people. When excluding Israel transplant. and Tunisia, the remaining countries cover a general population of 684.3 million people. This represents 81.1% of the 2017 the data, along with the complete results, can be found in the European general population, which is similar when com- ERA-EDTA Registry 2017 Annual Report [1]. pared with the 80.5% covered in the 2016 Aannual Rreport [2]. A total of 32 national or regional renal registries from 17 coun- tries provided individual patient data to the ERA-EDTA RESULTS Registry, whereas another 21 countries or regions provided Incidence of RRT aggregated data (Appendix 1). Compared with our 2016 Annual Report, the Canary Islands (Spain) are now included In 2017, 88 453 individuals out of a population of 694 million with individual patient data and Kosovo with aggregated started RRT for ESRD, resulting in an overall unadjusted inci- data, whereas data for the Valencia region (Spain) could not dence of 127 per million population (pmp; Table 1). The unad- be included this year. justed incidence ranged from 37, 66 and 67 pmp in Ukraine, This article presents the 2017 incidence and prevalence of Estonia and Russia, respectively, to 236, 242 and 252 pmp in RRT, kidney transplantation activity and both patient and graft Cyprus, the Sfax region (Tunisia) and Greece, respectively survival. A detailed description of the methods used to analyse (Table 1; Figures 1 and 2). Of the patients starting RRT, 62% ERA-EDTA Registry Annual Report 2017 | 699 were men, 52% were 65 years of age and 23% had diabetes mellitus (DM) as their primary renal disease (Figure 3). The median age of the patients starting RRT differed by >20 years between Albania (52.1 years) and Greece (74.0 years; Table 1), whereas the median age in all countries and regions com- bined was 66.2 years. The vast majority (85%) of patients started RRT with haemodialysis (HD), while 11% started with peritoneal dialysis (PD) and only 4% of patients received a pre- emptive kidney transplant (Figure 4). Nevertheless, there were considerable differences in the initial treatment modality be- tween age groups, with decreasing proportions of patients re- ceiving either PD or a pre-emptive transplant with increasing age (Figure 4). Moreover, compared with patients without a primary renal disease of DM, those with DM more often started RRT on HD (85% versus 80%) and less frequently re- ceived a pre-emptive kidney transplant (2% versus 6%). Among the incident patients receiving RRT at Day 91 after the start of treatment, 82% were receiving HD, 13% were receiving PD and 5% were living with a functioning kidney transplant (Figure 5). When compared with Day 1, the percentage of patients receiving HD decreased, which was particularly evi- dent in the younger age groups. Prevalence of RRT On 31 December 2017, 592 779 patients were receiving RRT for ESRD (Table 2), corresponding to an overall unadjusted preva- lence of 854 pmp. Among the individual countries/regions, the unadjusted prevalence ranged from 210, 319 and 333 pmp in Ukraine, Kosovo and Russia, respectively, to 1400, 1427 and 1965 pmp in the Canary Island (Spain), Catalonia (Spain) and Portugal, respectively (Table 2; Figures 6 and 7). Of the prevalent patients, 60% were men, 43% were 65 years and 16% had DM as their primary renal disease (Figure 8). The median age of prevalent patients receiving RRT in all countries and regions combined was 62.6 years; in individual countries, it ranged from 50.5 years in Albania to 68.4 years in the Dutch-speaking part of Belgium and Israel (Table 2). Of prevalent patients, 57% were re- ceiving HD, 37% were living with a kidney transplant and 5% were receiving PD (Figure 9). Compared with prevalent patients without DM as their primary renal disease, those with DM were less likely to be living with a functioning kidney transplant (51% versus 28%). Kidney transplantation In 2017, 22 902 kidney transplantations were performed, equat- ing to an overall unadjusted transplant rate of 33 pmp (Figure 10). In the individual countries/regions, the unadjusted kidney transplant rates ranged between 3 pmp in Ukraine and 6 pmp in Bulgaria and Kosovo to 79 and 83 pmp in Cantabria (Spain) and Basque Country (Spain), respectively, and even ex- ceeding 100 pmp in Catalonia (Spain). Overall, the unadjusted deceased donor kidney transplant rate was more than twice that of living donor transplants [23 versus 10 pmp (71% versus 29%); Figures 11 and 12]. The highest unadjusted rates of de- FIGURE 5: Treatment modality distribution, at Day 91, by (A) type of data pro- ceased donor kidney transplants were observed in several vided, (B) age, (C) sex and (D) primary renal disease (DM and non-DM) for inci- dent patients accepted for RRT in 2017. (B–D) Based on the data from registries Spanish regions (>70 pmp; Figure 12), whereas the highest providing individual patient data. See Appendix A1 for a list of countries and unadjusted rates of living donor transplants were observed in regions providing individual patient data or aggregated data. Tx, kidney Northern Ireland (37 pmp), Turkey (33 pmp) and The transplant. Netherlands (31 pmp; Figure 12). 700 | A. Kramer et al. Table 2. Prevalence of RRT on 31 December 2017, by country/region, presented as count (n) and unadjusted rate pmp, mean and median age on 31 December 2017 and the number and rate of patients with types 1 and 2 DM as primary renal disease Prevalent patients on RRT in 2017 General population covered All All Mean Median DM DM Country/region by the registry in thousands (n) (Pmp) age (years) age (years) (n) (Pmp) Albania 2847 1557 547 49.5 50.5 331 116 Austria 8773 9540 1087 61.6 63.1 1874 214 Belarus 9492 4295 452 593 62 Belgium, Dutch-speakinga 6543 8419 1287 66.3 68.4 1441 220 Belgium, French-speakinga 4832 6506 1346 65.1 66.8 1177 244 Bosnia and Herzegovina 3531 2644 749 59.7 61.4 520 147 Bulgaria 7050 4421 627 Croatia 3713 4635 1248 65.7 67.0 919 248 Cyprus 864 Czech Republic 9920 11 666 1176 Denmark 5821 5579 958 59.0 60.6 951 163 Estonia 1317 949 720 58.2 58.9 168 128 Finland 5508 5008 909 59.4 61.7 1270 231 France 66 865 87 989 1316 63.0 65.0 14 423 216 Georgia 3726 2972 798 59.8 61.0 590 158 Greece 10 755 14 183 1319 65.0 67.0 2676 249 Iceland 343 261 760 56.4 58.4 26 76 Israelb 8713 6692 768 66.3 68.3 3132 359 Italy (6 of 20 regions) 26 298 30 191 1137 62.6 64.8 3920 148 Kosovo 1688 539 319 63.2 66.0 159 94 Latvia 1547 1058 684 56.4 58.0 102 66 Lithuania 2848 2268 796 North Macedonia 2022 1761 871 59.0 60.0 300 148 Norway 5277 5155 977 59.7 61.7 707 134 Poland 38 430 30 278 788 5200 135 Portugal 10 310 20 259 1965 67.9 68.4 3511 341 Romania 19 000 21 708 1143 61.8 63.6 2189 115 Russia 142 473 47 486 333 54.2 57.0 6696 47 Serbia 6810 4850 712 58.7 61.2 835 123 Slovakiab 5437 3559 655 63.6 66.0 1177 216 Spain (all regions) 46 572 59 810 1284 59.5 62.7 9714 209 Spain, Andalusia 8409 10 296 1224 60.8 62.1 1604 191 Spain, Aragon 1315 1671 1271 63.4 64.7 299 227 Spain, Asturias 1034 1375 1329 63.4 64.5 226 219 Spain, Basque Country 2169 2722 1255 62.1 63.9 318 147 Spain, Canary Islands 2166 3032 1400 61.3 62.5 340 157 Spain, Cantabriaa 581 637 1096 62.3 63.6 92 158 Spain, Castile and Leóna 2427 3031 1249 65.3 66.1 549 226 Spain, Castile-La Manchaa 2037 2422 1189 62.8 63.6 393 193 Spain, Catalonia 7556 10 785 1427 63.2 65.0 1520 201 Spain, Community of Madrid 6507 7537 1158 62.1 63.5 1345 207 Spain, Extremadura 1080 1274 1180 62.0 62.7 194 180 Spain, Galicia 2707 3741 1382 62.9 64.3 627 232 Spain, Murcia 1470 1982 1348 62.4 63.3 283 192 Spain, Navarrea 642 860 1339 62.8 64.3 123 192 Sweden 10 058 9927 987 60.0 62.0 1776 177 Switzerland 8452 7927 938 62.2 64.1 1176 139 The Netherlands 16 617 17 246 1038 60.7 62.6 2308 139 Tunisia, Sfax regionb 990 1007 1018 58.6 60.0 211 213 Turkeyc 80 811 77 311 957 2366 29 UK, Englanda,d 55 619 54 043 972 58.9 59.4 9417 169 UK, Northern Irelanda 1871 1831 979 59.0 58.8 273 146 UK, Scotland 5425 5184 956 56.8 57.8 847 156 UK, Walesa 3125 3161 1011 59.5 60.4 520 166 Ukraine 42 415 8904 210 50.0 51.0 1358 32 All countries 694 709 592 779 854 60.7 62.6 84 853 141 When cells are left empty, the data were unavailable and could not be used for the calculation of the summary data. a Patients <20 years of age are not reported. The true prevalent counts are therefore slightly higher than the counts reported here. b Data on prevalence include dialysis patients only. c Data on primary renal disease (DM) is based on 6888 dialysis patients (8.9%; total n ¼ 77 311). d The prevalence is underestimated by 1% due to one centre not submitting data since 2014. ERA-EDTA Registry Annual Report 2017 | 701 FIGURE 6: Prevalence (pmp) of RRT on 31 December 2017 by country/region. The prevalence of Israel, Slovakia and Sfax region (Tunisia) only includes patients receiving dialysis. For England (UK), the prevalence is underestimated by 1% (Table 2). 702 | A. Kramer et al. FIGURE 7: Unadjusted (left panel) and adjusted (right panel) prevalence (pmp) of RRT on 31 December 2017 by country/region. Registries providing individual patient data are shown as dark bars and registries providing aggregated data as light bars. Adjustment of the prevalence was performed by standardizing the prevalence to the age and sex distribution of the EU27 population. The prevalence of Israel only includes patients receiving dialysis. For England (UK), the prevalence is underestimated by 1% (Table 2). ERA-EDTA Registry Annual Report 2017 | 703 FIGURE 8: (A) Sex, (B) age and (C) primary renal disease distribution by type of data provided for prevalent patients on RRT on 31 December 2017. See Appendix A1 for a list of countries and regions providing individual patient data or aggre- gated data. Survival of patients receiving RRT FIGURE 9: Treatment modality distribution by (A) type of data provided, (B) age, For patients commencing RRT in the period 2008–12, the 5-year (C) sex and (D) primary renal disease (DM and non-DM) for prevalent patients on RRT on 31 December 2017. (B–D) Based on the data from registries providing in- unadjusted patient survival probability for all RRT modalities dividual patient data. See Appendix A1 for a list of countries and regions provid- combined was 50.8% [95% confidence interval (CI) 50.7–51.0]. For ing individual patient data or aggregated data. Tx, kidney transplant. patients starting RRT with dialysis in this period, the unad- justed 5-year patient survival probability was 42.2% (95% CI 42.1–42.4). Adjusted analyses for patient survival on HD and PD Expected remaining lifetime revealed higher survival probabilities in the first 3 years for There was a substantial difference in the expected remaining those receiving PD (Figure 13). For patients receiving a kidney lifetime between patients receiving dialysis between 2013 and transplant in the period 2008–12, living donor transplant recip- 2017 and the general population (Figure 14). Although patients ients experienced a higher adjusted 5-year patient survival living with a functioning kidney transplant have a longer life ex- than recipients of deceased donor transplants [94.6% (95% CI pectancy than those receiving dialysis, it is still lower than that 94.2–95.1) versus 92.1% (95% CI 91.8–92.4)], as well as a higher of the age-matched general population. With the advancing age adjusted 5-year graft survival [86.7% (95% CI 86.0–87.4) versus of kidney transplant recipients, the relative difference in the 81.4% (95% CI 80.9–81.9)]. See Table 3 for a description of the expected remaining lifetime compared with the age-matched adjustments made and the countries/regions included in these general population increases, although the absolute difference analyses. decreases. 704 | A. Kramer et al. FIGURE 10: Kidney transplants performed in 2017, presented as counts and pmp (unadjusted) by country/region. Registries providing individual patient data are shown as red bars and registries providing aggregated data as orange bars. The total count for Austria is based on residents and non-residents. For Romania, Serbia and England (UK), the overall kidney transplant rate is underestimated by 30, 15 and 7%, respectively. ERA-EDTA Registry Annual Report 2017 | 705 and Spanish Society of Nephrology (SEN); Swedish Renal Registry: M. Stendahl, H. Rydell, M. Evans, K.G. Prütz, T. Lundgren and M. Segelmark; Swiss Dialysis Registry: P. Ambühl and R. Winzeler; Dutch Renal Registry (RENINE): L. Heuveling, S. Vogelaar and M. Hemmelder; Tunisia, Sfax re- gion: F. Jarraya and D. Zalila; Registry of the Nephrology, Dialysis and Transplantation in Turkey (TSNNR): G. Süleymanlar, N. Seyahi and K. Ateş; Ukrainian Renal Data System (URDS): M. Kolesnyk, S. Nikolaenko and O. Razvazhaieva; UK Renal Registry: all the staff of the UK Renal Registry and of the renal units submitting data; Scottish Renal Registry: all of the Scottish renal units); and the re- gional registries of Andalusia (SICATA): P. Castro de la Nuez (on behalf of all users of SICATA); Aragon: F. Arribas Monzón, J.M. Abad Diez and J.I. Sanchez Miret; Asturias: P. Beltrán, J.R. Quirós and RERCA Working Group; Basque Country (UNIPAR): Á. Magaz, J. Aranzabal, M. Rodrigo and I. Moina; Canary FIGURE 11: Donor-type distribution for kidney transplants performed in 2017, by Islands: H. Sánchez Janáriz; Cantabria: J.C. Ruiz San Millán, O. type of data provided. See Appendix A1 for a list of countries and regions provid- Garcia Ruiz and C. Pin ~ era Haces; Castile and León: M.A. ing individual patient data or aggregated data. Palencia Garcı́a; Castile-La Mancha: G. Gutiérrez Ávila and I. Moreno Alı́a; Catalonia (RMRC): E. Arcos, J. Comas and J. Tort; Community of Madrid: M.I. Aparicio de Madre; Extremadura: AFFILIATED REGISTRIES all the renal units (Nephrology and Dialysis); Galicia: E. Bouzas-Caaman ~ o; Renal Registry of the Region of Murcia: C. Albanian Renal Registry: M. Barbullushi, A. Idrizi and E. Santiuste de Pablos and I. Marı́n Sánchez; and Navarre: M.F. Bolleku Likaj; Austrian Dialysis and Transplant Registry Slon Roblero, J. Manrique Escola and J. Arteaga Coloma. (OEDTR): R. Kramar; Belarus Renal Registry: K.S. Komissarov, K.S. Kamisarau and A.V. Kalachyk; Dutch-speaking Belgian Society of Nephrology (NBVN): M. Couttenye, F. Schroven and ERA-EDTA REGISTRY COMMITTEE MEMBERS J. De Meester; French-speaking Belgian Society of Nephrology C. Zoccali (Italy; ERA-EDTA President), Z.A. Massy (France, (GNFB): J.M. des Grottes and F. Collart; Renal Registry Bosnia , B. Jakovljevic and M. Tomi Chairman), P. Ambühl (Switzerland), M. Arici (Turkey), M. Evans and Herzegovina: H. Resic c; (Sweden), P. Finne (Finland), J. Harambat (France), L. Mercadal Bulgarian Renal Registry: E.S. Vazelov and I. Velinova; Croatian Registry of Renal Replacement Therapy (CRRRT): I. (France), M. Nordio (Italy), S.S. Sørensen (Denmark) and E. Vidal Bubic and M. Knotek; Cyprus Renal Registry: K. Ioannou and (Italy). all of the renal units providing data; Czech Republic Registry of Dialysis Patients (RDP): I. Rychlı́k, J. Potucek and F. Lopot; ERA-EDTA REGISTRY OFFICE STAFF Danish Nephrology Registry (DNS): J.G. Heaf; Estonian Society of Nephrology: Ü. Pechter, K. Lilienthal and M. Rosenberg; K.J. Jager (Managing Director), M. Bonthuis (for the paediatric Finnish Registry for Kidney Diseases: P. Finne, J. Helve and section), R. Boenink, J.R. Bosdriesz, R. Cornet, G. Guggenheim, A. P.H. Groop; France – Renal Epidemiology and Information Kramer, M. Noordzij, V.S. Stel and A.J. Weerstra. Network (REIN): M. Lassalle and C. Couchoud; Georgian Renal Registry: N. Kantaria and Dialysis Nephrology and ACKNOWLEDGEMENTS Transplantation Union of Georgia; Hellenic Renal Registry: G. Moustakas; Icelandic End-Stage Renal Disease Registry: R. The ERA-EDTA Registry would like to thank the patients Pálsson; Israel National Registry of Renal Replacement and staff of all the dialysis and transplant units who Therapy: R. Dichtiar, L. Keinan-Boker and E. Golan; Italian have contributed data via their national and regional re- Registry of Dialysis and Transplantation (RIDT): A. Limido, M. nal registries. In addition, we would like to thank the Nordio and M. Postorino; Kosovo Renal Registry: H. Korca, S. persons and organizations listed in the ‘Affiliated Selmani and M. Tolaj-Avdiu; Latvian Renal Registry: H. Registries’ section for their contribution to the work of Cernevskis, V. Kuzema and A. Popova; Lithuanian Renal the ERA-EDTA Registry.  Registry: V. Vainauskas, K. Petruliene and E. Ziginskiené; Macedonian Renal Registry: O. Stojceva-Taneva and N. Dimitriova; Norwegian Renal Registry: A.V. Reisæter and A. FUNDING Åsberg; Polish Renal Registry: A. De  R bska-Slizie  , R. Gellert n The ERA-EDTA Registry is funded by the ERA-EDTA. This and G. Korejwo; Portuguese Renal Registry: F. Macário and A. article was written by Kramer et al. on behalf of the ERA- Ferreira; Romanian Renal Registry (RRR): G. Mircescu, L. EDTA Registry, which is an official body of the ERA-EDTA. Garneata and E. Podgoreanu; Russian Renal Registry: N. Tomilina, A. Andrusev and H. Zakharova; Renal Registry in In addition, M.F.S.R. reports personal fees from NxStage Serbia: M. Lausevic, R. Naumovic, all of the Serbian renal outside the submitted work and K.J.J. reports grants from units and the Serbian Society of Nephrology; Slovakian Renal the ERA-EDTA during the conduct of the study and a Registry: V. Spustová, I. Lajdová and M. Karolyova; Spanish speaker fee from Fresenius Medical Care outside the sub- RRT National Registry at ONT, Spanish Regional Registries mitted work. 706 | A. Kramer et al. FIGURE 12: Deceased donor (left panel) and living donor (right panel) kidney transplants performed in 2017 pmp, by country/region, unadjusted. Registries providing in- dividual patient data are shown as dark bars and registries providing aggregated data as light bars. The total count for Austria is based on residents and non-residents. For Romania and England (UK), the kidney transplant rate is underestimated by 30 and 7%, respectively. For Serbia, the transplant rate is underestimated by 16% for de- ceased donor transplants and by 12% for living donor transplants. ERA-EDTA Registry Annual Report 2017 | 707 FIGURE 13: Survival of patients starting HD and PD between 2008 and 2012 from Day 91 (left panel) and patients receiving a first kidney transplant from a living or de- ceased donor between 2008 and 2012 (right panel). Survival on dialysis was censored for kidney transplantation and adjusted using fixed values for age (67 years), sex (63% men) and primary renal disease (24% DM, 19% hypertension/renal vascular disease, 11% glomerulonephritis and 46% other causes). Survival after kidney trans- plantation was adjusted using fixed values for age (50 years), sex (63% men) and primary renal disease (14% DM, 10% hypertension/renal vascular disease, 23% glomeru- lonephritis and 53% other causes). These figures are based on data from the following registries providing individual patient data: Austria, Belgium (Dutch-speaking), Belgium (French-speaking), Denmark, Finland, France, Greece, Iceland, Norway, Spain (Andalusia), Spain (Aragon), Spain (Asturias), Spain (Basque Country), Spain (Cantabria), Spain (Castile and León), Spain (Castile-La Mancha), Spain (Catalonia), Spain (Extremadura), Spain (Galicia), Spain (Community of Madrid), Sweden, The Netherlands, UK (England, Northern Ireland, Wales) and UK (Scotland). Table 3. The survival probabilities at 1, 2 and 5 years by treatment modality and cohort from Day 1 of the start of RRT/dialysis or from the day of kidney transplantation Survival probabilities as a percentage (95% CI) Cohort: 2008–12 Cohort: 2011–15 Survival type 1 year 2 years 5 years 1 year 2 years Patient survival on RRT Unadjusted 83.9 (83.7–84.0) 73.7 (73.6–73.9) 50.8 (50.7–51.0) 84.8 (84.6–84.9) 74.8 (74.6–74.9) Adjusteda 86.6 (86.4–86.7) 77.2 (77.0–77.4) 52.4 (52.1–52.7) 87.2 (87.1–87.4) 78.0 (77.8–78.2) Patient survival on dialysis Unadjusted 82.8 (82.6–82.9) 71.2 (71.0–71.4) 42.2 (42.1–42.4) 83.6 (83.5–83.8) 72.1 (72.0–72.3) Adjusteda 84.9 (84.8–85.1) 74.4 (74.2–74.6) 45.7 (45.4–46.1) 85.9 (85.8–86.1) 75.6 (75.4–75.9) Patient survival after first kidney transplantation (deceased donor) Unadjusted 96.3 (96.1–96.5) 94.3 (94.0–94.5) 87.3 (87.0–87.6) 96.3 (96.1–96.5) 94.2 (94.0–94.5) Adjustedb 97.8 (97.7–98.0) 96.6 (96.4–96.8) 92.1 (91.8–92.4) 98.0 (97.9–98.1) 96.8 (96.7–97.0) Graft survival after first kidney transplantation (deceased donor) Unadjusted 91.2 (90.9–91.5) 88.3 (88.0–88.6) 78.6 (78.2–79.0) 91.4 (91.1–91.7) 88.3 (88.0–88.6) Adjustedb 92.6 (92.3–92.9) 90.0 (89.7–90.4) 81.4 (80.9–81.9) 93.1 (92.9–93.4) 90.6 (90.3–91.0) Patient survival after first kidney transplantation (living donor) Unadjusted 98.8 (98.6–99.0) 97.9 (97.6–98.2) 93.9 (93.5–94.4) 99.0 (98.8–99.2) 98.1 (97.8–98.3) 708 | A. Kramer et al. Table 3. (continued) Survival probabilities as a percentage (95% CI) Cohort: 2008–12 Cohort: 2011–15 Survival type 1 year 2 years 5 years 1 year 2 years Adjustedb 99.0 (98.8–99.2) 98.2 (98.0–98.5) 94.6 (94.2–95.1) 99.2 (99.0–99.3) 98.4 (98.1–98.6) Graft survival after first kidney transplantation (living donor) Unadjusted 96.3 (96.0–96.7) 94.6 (94.2–95.0) 87.5 (86.9–88.1) 96.9 (96.5–97.2) 95.1 (94.7–95.5) Adjustedb 96.1 (95.7–96.5) 94.3 (93.8–94.8) 86.7 (86.0–87.4) 96.7 (96.3–97.0) 94.9 (94.5–95.3) The findings are based on data from the following renal registries providing individual patient data: Austria, Belgium (Dutch-speaking), Belgium (French-speaking), Denmark, Finland, France, Greece, Iceland, Norway, Spain (Andalusia), Spain (Aragon), Spain (Asturias), Spain (Basque Country), Spain (Cantabria), Spain (Castile and León), Spain (Castile-La Mancha), Spain (Catalonia), Spain (Community of Madrid), Spain (Extremadura), Spain (Galicia), Sweden, The Netherlands, UK (England, Northern Ireland, Wales) and UK (Scotland). Unadjusted survival probabilities were calculated using the Kaplan–Meier method and adjusted survival probabilities using the Cox regression model. a Analyses were adjusted using fixed values: age (67 years), sex (63% men) and primary renal disease (24% DM, 19% hypertension/renal vascular disease, 11% glomerulo- nephritis and 46% other causes). b Analyses were adjusted using fixed values: age (50 years), sex (63% men) and primary renal disease (14% DM, 10% hypertension/renal vascular disease, 23% glomerulo- nephritis and 53% other causes). CONFLICT OF INTEREST STATEMENT None declared. REFERENCES 1. ERA-EDTA Registry. ERA-EDTA Registry Annual Report 2017. Amsterdam: Amsterdam UMC, Department of Medical Informatics, 2019 2. Kramer A, Pippias M, Noordzij M et al. The European Renal Association–European Dialysis and Transplant Association (ERA-EDTA) Registry Annual Report 2016: a summary. Clin Kidney J 2019; 12: 702–720 FIGURE 14: Expected remaining lifetimes of prevalent dialysis and kidney transplant patients (cohort 2013–17) and the general population (cohort 2013–17), by age. This figure is based on data from the following registries providing individual patient data: Austria, Belgium (Dutch-speaking), Belgium (French-speaking), Denmark, Finland, France, Greece, Iceland, Norway, Spain (Andalusia), Spain (Aragon), Spain (Asturias), Spain (Basque Country), Spain (Cantabria), Spain (Castile and León), Spain (Castile-La Mancha), Spain (Catalonia), Spain (Extremadura), Spain (Galicia), Spain (Community of Madrid), Sweden, The Netherlands and UK (all countries). ERA-EDTA Registry Annual Report 2017 | 709 Appendix 1 platinum, nephropathy (interstitial) due to cyclosporin A, lead- induced nephropathy (interstitial), drug-induced nephropathy Countries or regions providing individual patient data to the (interstitial) not mentioned above, cystic kidney disease–type ERA-EDTA Registry: Austria; Dutch-speaking Belgium; French- unspecified, polycystic kidneys– infantile (recessive), medullary speaking Belgium; Bosnia and Herzegovina; Denmark; Estonia; cystic disease, including nephronophthisis, cystic kidney dis- Finland; France; Greece; Iceland; Norway; Romania; Serbia; the ease – other specified type, hereditary/familial nephropathy – Spanish regions of Andalusia, Aragon, Asturias, Basque Country, type unspecified, hereditary nephritis with nerve deafness Canary Islands, Cantabria, Castile and León, Castile-La Mancha, (Alport’s syndrome), cystinosis, primary oxalosis, Fabry’s dis- Catalonia, Community of Madrid, Extremadura, Galicia, Murcia ease, hereditary nephropathy – other specified type, renal hypo- and Navarre; Sweden; Switzerland; The Netherlands; UK plasia (congenital) – type unspecified, oligomeganephronic (England, Northern Ireland ,Wales and Scotland). Countries or regions providing aggregated data to the ERA- hypoplasia, congenital renal dysplasia with or without urinary EDTA Registry: Albania, Belarus, Bulgaria, Croatia, Cyprus, the tract malformation, syndrome of agenesis of abdominal Czech Republic, Georgia, Israel, Italy, Kosovo, Latvia, Lithuania, muscles (prune belly), renal vascular disease due to polyarteri- North Macedonia, Poland, Portugal, Russia, Slovakia, Spain, Sfax tis, Wegener’s granulomatosis, ischemic renal disease/choles- region (Tunisia), Turkey and Ukraine. terol embolism, glomerulonephritis related to liver cirrhosis, Countries not providing data to the ERA-EDTA Registry: cryoglobulinemic glomerulonephritis, myelomatosis/light chain Andorra, Armenia, Azerbaijan, Germany, Hungary, Ireland, deposit disease, amyloid, lupus erythematosus, Henoch– Liechtenstein, Luxembourg, Malta, Moldova, Monaco, San Schönlein purpura, Goodpasture’s syndrome, systemic sclerosis Marino and Slovenia. (scleroderma), haemolytic–uraemic syndrome (including Moschcowitz syndrome), multisystem disease – other (not men- tioned above), tubular necrosis (irreversible) or cortical necrosis, Appendix 2 tuberculosis, gout, nephrocalcinosis and hypercalcemic ne- Miscellaneous primary renal diseases: nephropathy (interstitial) phropathy, Balkan nephropathy, kidney tumour, traumatic or due to analgesic drugs, nephropathy (interstitial) due to cis- surgical loss of kidney and other identified renal disorders.