Nephrology and renal replacement therapy in Romania transition still continues (Cinderella story revisited)

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1 Nephrol Dial Transplant (2004) 19: doi: /ndt/gfh501 Dialysis and Transplantation News Nephrology and renal replacement therapy in Romania transition still continues (Cinderella story revisited) Gabriel Mircescu 1,2, Dimitrie Caps a 2, Maria Covic 2, Mirela Gherman Căprioară 2, Gheorghe Gluhovschi 2, Ovidiu Golea 2, Nicolae Ursea 1, Liliana Gârneat ă 1, Vasile Cepoi 3, Nicolae Constantinovici 1 and Adrian Covic 2,3 for the Romanian Renal Registry 1 Dr. Carol Davila University Hospital of Nephrology, Bucharest, 2 Romanian Society of Nephrology and 3 Dialysis and Transplantation Center, University Hospital, Dr. C.I. Parhon, Ias i, Romania Abstract Introduction. This report describes the current status of nephrology and renal replacement therapy (RRT) in Romania, a country with previously limited facilities, highlighting national changes in the European context. Methods. Trends in RRT development were analysed in 2003, on a national basis, using the same questionnaires as in previous surveys (1991, 1995). Survival data and prognostic risk factors were calculated retrospectively from a large representative sample of 2284 patients starting RRT between January 1, 1995 and December 31, 2001 (44% of the total RRT population investigated). Results. In 2003, RRT incidence [128 per million population (p.m.p.)] and prevalence (250 p.m.p.) were six and five times higher, respectively, than in The annual rate of increase in the stock of RRT patients (11%) was supported mainly by an exponential development of the continuous ambulatory peritoneal dialysis (CAPD) population (þ600%), while the haemodialysis (HD) growth rate was stable (þ33%) and renal transplantation made a marginal contribution. Renal care infrastructure followed the same trend: nephrology departments (þ100%) and nephrologists (þ205%). The characteristics of RRT incident patients changed accordingly to current European epidemiology (increasing age and prevalence of diabetes and nephroangiosclerosis). The estimated overall survival of RRT patients in Romania was 90.6% at 1 year [confidence interval (CI) ] and 62.2% at 5 years (CI ). Patients survival was negatively influenced (Cox regression analysis) by age >65 years (P<0.001), lack of pre-dialysis monitoring Correspondence and offprint requests to: Adrian Covic, MD PhD, Professor of Nephrology, Parhon University Hospital, 50 Carol 1st Blvd, Iasi 6600, Romania. acovic@xnet.ro by a nephrologist [P ¼ 0.01, hazards ratio (HR) ¼ 0.8], severe anaemia, lack of erythropoetin treatment (P<0.001, HR ¼ 0.6), and co-morbidity, e.g. cardiovascular diseases (P<0.001, HR ¼ 1.8) and diabetes mellitus (P<0.001, HR ¼ 2.2). Conclusions. Although the rate of increase in RRT patient stock in in Romania was the highest in Europe, the prevalence remained below the European mean. As CAPD had the greatest expansion, followed by HD, an effective transplantation programme must be set up to overcome the imbalance. The quality of RRT appears to be good and survival was similar to that in other registries. Further evolution implies strategies of prevention, based on national surveys, supported by the Romanian Renal Registry. Keywords: CAPD; HD; registry; renal replacement therapy; survival; transplantation Introduction In the context of the transformation of the health systems in Central and Eastern European countries following the fall of the communist regimes, Romania had one of the fastest growing rates of dialysis facilities and development of the renal care infrastructure. A comprehensive report on the period was published previously in the news section of Nephrology Dialysis Transplantation [1]. Although rates of increase in the numbers of Nephrology Departments (þ82%), haemodialysis (HD) centres (þ142%), and total number of patients alive on renal replacement therapy (RRT) (þ196%) were higher than the European mean, in 1995 only 27 30% of the Nephrol Dial Transplant Vol. 19 No. 12 ß ERA EDTA 2004; all rights reserved

2 2972 G. Mircescu et al. incident uraemic patients could be saved by RRT. Moreover, only 20% of children (age <15 years) and people over 55 requiring RRT actually received this treatment, while diabetics represented <5% of the endstage renal disease (ESRD) population. In the following 8 years ( ), under the combined pressure of local and medical communities, additional structural changes took place. In 1995, continuous ambulatory peritoneal dialysis (CAPD) was initiated in Romania with excellent results [2]. New HD centres were developed, so that previously restrictive inclusion criteria changed and became similar to current European norms. The Romanian Society of Nephrology s interest in the quality of renal replacement treatments imposed strict accreditation criteria for dialysis units, best clinical practice guidelines and continuous medical education programmes. More recently, the (Public) Health Insurance House was founded (1999). Initially, the reimbursement policy for RRT was based on historical criteria rather than on real operating costs. In 2001, a centralized acquisition policy for dialysis consumables was set up a rare practice for European countries. The aim of this report is to present the current status of nephrology and RRT in Romania, a former communist country with previously limited facilities, but with a fast development, highlighting significant changes in the last 8 years, in the context of regional and European data. completed by the nephrologists in charge of the patients, based on patients medical records. The following items were requested: demographic characteristics, diabetic status, presence of cardiovascular disease (defined as heart failure, documented coronary artery disease, peripheral arterial or cerebrovascular disease), previous care by a nephrologist, emergency dialysis initiation, dialysis access and type, haemoglobin level and erythropoetin treatment at dialysis initiation. All patients starting maintenance dialysis from January 1, 1995 to December 31, 2001, surviving at least 3 months on the initial RRT method, were included. A careful revision of data received from all centres was performed. Only 14 centres reported complete data for all patients; centres with missing data were excluded from the analysis. The retrospective analysis was performed at the end of 2002, and included 2284 patients (44% of the total national dialysis population) for a period of 7 years. Statistical analysis was performed using an SPSS 10 package. Data are presented as mean±sd. The presence of a linear trend of variation was assessed by univariate ANOVA. Overall patients survival probability was estimated using the actuarial method. The influence of each prognostic factor was evaluated by the Kaplan Meier method; a log rank P-value <0.05 was considered to indicate a significant difference between subgroup survival curves. The adjusted predictive value of each factor was analysed within a multivariate Cox regression model. Projections were made assuming a linear increase of the actual trends, i.e. the same incidence, the same proportion of methods and the same rates of death and drop-out. Methods Previous national surveys were performed on January 1, 1991 (baseline evaluation 1 year following the change of the political regime in Romania) and on January 1, 1996 (Romanian Renal Registry evaluation following the implementation of the 5 year Program of Development of Nephrology and Renal Replacement Therapy in Romania ). Detailed information concerning the following items was requested: (i) centre infrastructure/equipment (date of establishment, number of HD units, type of water treatment station and number of nephrological beds); (ii) human resources (number of physicians, nurses and auxiliary personnel); (iii) RRT patients (primary renal disease, age at start of RRT and type of RRT); and (iv) cost of RRT. In 2002, the Romanian Renal Registry performed a third, similar, national survey, including all 71 dialysis units in Romania. Complete data were returned by 67 (rate of response ¼ 94%) [1,3]. Additionally, detailed data on RRT were collected using centre questionnaires sent yearly, as described in our previous report [1]. As data were compared with previous reports of each centre and were used to budget centres, it is likely that they were accurate. Point prevalence at December 31 and incident patients from the previous year were used. To estimate survival data and risk factors accurately for dialysis patients, a more detailed individual patient questionnaire was sent by post to 16 centres (representing 16 different counties selected from all the seven historical provinces, i.e. 39% from the total Romanian administrative units). The data for the survival cohort were collected retrospectively using individual patient questionnaires Results Development of renal replacement therapies Presently, Romania has a population of , a 4% decrease from 1997, with 47% still living in rural areas. The Gross Domestic Product (GDP) increased from US$34.9 billion in 1997 to US$45.7 billion in 2001 [4]. The health budget increased from 2.6% of the GDP in 1997 to 6.7% in 2003; health expenses per capita increased from US$41 to US$510/year. Currently, the ESRD incidence is 128 per million population (p.m.p.), almost six times more than in 1996 [1,3]. The total number of patients on RRT at January 1, 2003 is 5447 (2.6% paediatric cases), i.e. a median prevalence of 250 treated ESRD cases p.m.p. (Table 1). A comparison with previous national data depicting trends in RRT is presented in Figure 1. Although highly variable from year to year, the rate of increase in the stock of dialysis patients was >11% per year, during the interval (as shown in Figure 2), above the world mean of 7% [5]. It is important to note that CAPD implementation in 1995 was followed by an exponential development of the CAPD population, while the rate of increase in the HD population remained stable and renal transplantation made only a marginal contribution to the global expansion, because of the reduced number of grafts performed per year.

3 Nephrology and renal replacement therapy in Romania ,000 Table 1. Trends in Romanian nephrology ( ) 5, Change (1996 vs 2003, 1996 ¼ 100%) 4,500 4,236 Population (millions) % Departments of þ180% nephrology (n) Physicians (n) þ205% Board-certified þ45% nephrologists (%) Trainees in nephrology (n) þ69% Dialysis centres (n) þ238% HD machines (n) þ217% Transplant centres (n) þ100% Haemodialysis Schedule (4 h/session, three sessions/week, % of centres) Bicarbonate dialysis 5 95 (% of sessions) Non-cellulose, biocompatible membranes (% of sessions) Haemodiafiltration on-line (% of sessions) Low molecular weight heparin (% of patients) Erythropoetin use (% of patients) Peritoneal dialysis CAPD (CCPD) 100% 94% (0%) (6%) Peritonitis rate (episodes/patient/year) Renal transplantation No. of grafts per year Percentage from living donor Incident RRT patients Number þ508% p.m.p Prevalent RRT patients HD Number þ264% p.m.p PD Number þ4660% p.m.p RTx Number þ121% p.m.p Total Number 439 1, þ319% p.m.p Age over 55 year at þ60 RRT initiation (%) Gender (male %) % Diabetic renal disease (%) þ117% Mortality rate (per 100 RRT patients per year) 11.7% 11.8% 12% þ1.7% Resources: renal centres and nephrologists Thirty years after the foundation of the first HD unit, there are 3.2 dialysis centres p.m.p. in Romania, still below the reported mean for this European region 3,000 1,500 Rateofincrease (%vs previous year) ,301 1, ,991 1,996 2,003 Total HD PD TR Fig. 1. Prevalent RRT patient count by method in Romania : the exponential increase was supported by haemodialysis and peritoneal dialysis. The lines represent trends for each specific RRT method for the period and beyond in 1998 (4.5 centres p.m.p.) [6,7]. However, major inequalities in dialysis facilities are still present between different counties (Figure 3). This heterogeneity is explained by important economic inequalities between counties, as well as by the presence of large academic affiliated hospitals in areas with the highest RRT prevalence. The number of HD machines increased to 780 (36 p.m.p.) in 2003, a dialysis capacity three times larger than in 1996, but still lower compared with Hungary or the Czech Republic (93 and 102 p.m.p., respectively). Most of the centres are running CAPD programmes and, in four, kidney transplantation is also performed. The number of Departments of Nephrology doubled from 1996; however, there are still six out of 41 counties with only dialysis facilities. Most of the nephrology practice continues to take place in hospitals, a feature of countries in transition: there are 50 hospital nephrology beds p.m.p. (more than in France; 33 p.m.p. [8]), but less than a half of the nephrology Total RRT HD PD RTx Fig. 2. Rate of increase (percentage, previous year ¼ 100%) of RRT patients by method in Romania : although decreasing from 1997, an impressive rate of over 11% was maintained each year. HD closely followed the general trend, PD had the highest rate of increase, while transplantation had the highest fluctuation

4 2974 G. Mircescu et al. AR 189 BH 317 SM 170 SJ 195 CJ 273 AB 196 MM 180 BN 209 MS HR 236 SV 190 NT 218 BT 181 BC 228 IS 439 Prevalent RRT patients(pmp) < la 250 > 300 VS 212 Renal transplantation was, and still is, the Cinderella of RRT in Romania. The number of grafts was, generally, under 60 per year per centre (only four centres), almost all from living donors. Most importantly, there are no national networks or nationally accepted protocols. TM 327 CS 189 HD 385 MH 428 GJ 345 DJ 169 SB 292 departments have out-patient services. Moreover, specialized investigations are also limited, e.g. renal biopsies and complete immunological investigations are available only in university hospitals. The number of nephrologists significantly increased: þ205% from the last survey (Table 1), reaching 10 physicians p.m.p., still a lower value than in France (15 p.m.p) and in the UK (13 p.m.p.) [9]. Since 25% of doctors working in HD units are still not boardcertified nephrologists a decreasing proportion from 1995 continuous medical education became a problem of major concern. A new curriculum (5 years) for nephrology trainees prepared by the Romanian Society of Nephrology according to European regulations was initiated in With the support of EDTA-ERA, ISN and of various national societies, numerous young Romanian nephrologists gained access to international educational courses and to training grants. Characteristics of renal replacement therapies BV 280 The most prevalent HD schedule remains three 4 h sessions per week (see Table 1). A slight increase in the proportion of biocompatible dialysis membranes (63 vs 51%) could be noted, and in the more liberal use of low molecular weight heparin (26 vs 1% of HD sessions previously). Water is treated by reverse osmosis in all centres and acetate solutions for dialysis virtually disappeared. These trends were similar to those noted elsewhere in the world [5]. Erythropoeitin therapy extended to 75% of HD patients, higher than the mean of the Central East European zone (47%), but doses per patient are suboptimal, judged by the mean haemoglobin values achieved (Table 3). CAPD continued to be the most used technique of peritoneal dialysis, although in the last 2 years, CCPD was introduced and extended to 10% of patients. Peritonitis rates declined to 0.5 episodes per patient per year, in spite of the major expansion of the pool of patients. CV VR 239 BZ VL PH 271 BR TL AG DB 154 IL B OT CL CT GR TR Fig. 3. Prevalence of RRT patients in the counties of Romania (2003): important inequalities are still present. GL 94 Romanian RRT in the context of Central and Eastern Europe To outline the described Romanian trend in RRT development, a comparative analysis with Poland, Hungary and the Czech Republic (countries that had and still have the most developed RRT network of the former Soviet area) and with Bulgaria (the country considered economically similar to Romania by the EU) was performed. Initially, Romania had the lowest development of renal services. Thereafter, Romania recorded the highest rate of growth in the region and in Europe, supported by the increase in GDP and, consequently, in health expenditure (Table 2). Although impressive, this high rate of growth was insufficient to cover the initial gap (Figure 4). More importantly, as shown in Figure 5, RRT development followed a different pattern in Romania, where the proportion of PD patients doubled, from that in the Czech Republic, Hungary or Poland, where most of the increase was noted in the proportion of transplantation patients. Undoubtedly, RRTs have high social costs and their trends rely heavily on both evolution of economy and political decisions. As illustrated in Figure 6, the variation in total prevalent RRT patients closely followed the total health and RRT expenditures. RRT patients Changes in the RRT population characteristics were extrapolated from the extensive cohort investigated for the survival analysis (Table 3). Age at RRT initiation significantly increased, but the proportion of patients over 65 years old is below the mean reported by Euro-DOPPS in Western Europe (47%) [10]. Significant trends were also observed in ESRD aetiology: doubling of diabetes and nephroangiosclerosis cases from 1996 to In 2002, the emergency initiation of RRT was reported in more than half of the incident patients. Mean haemoglobin at RRT initiation was still far below the accepted values (Table 3). All these reflect late referral and lack of nephrologist follow-up of the chronic renal failure population and had a significant impact on outcome (see above). Of particular interest from the perspective of renal transplantation is the important prevalence of patients with markers of hepatitis infection pre-rrt (HBV prevalence ¼ 15.7%), decreasing, but still high, as compared with Euro-DOPPS patients (3.1%) [11]. Finally, important co-morbidities were present at

5 Nephrology and renal replacement therapy in Romania 2975 Table 2. Trends in RRT development in selected Central Eastern European countries Czech Republic Hungary Poland Bulgaria Romania Year Change a Change Change Change Change Pop (million) Total health expenditure (%GDP) Total health expenditure per capita (US$) HD p.m.p % of total RRT DP p.m.p % of total RRT TR p.m.p % of total RRT Total , p.m.p a Mean percentual variation per year of observation (first year of observation ¼ 100%). Population and economic data from WHO, World Bank and OECD Health Data [4,24,25]. Data on RRT for the year 1995 from EDTA Registry Data on RRT for the year 2003 from the Czech Society of Nephrology, Polish Society of Nephrology and Romanian Renal Registry. Data on RRT for Hungary and Bulgaria (2001) from USRDS Annual Report (2003) [18].

6 2976 G. Mircescu et al Czech Rep Hungary Prevalent RRT pts first year Mean percentual change/year Poland Bulgaria Romania Prevalent RRT pts last year Fig. 4. The prevalence of RRT patients in the first and the last year of the interval (p.m.p.) and the mean percentage change per year (first year of observation ¼ 100%) in selected Central East European countries: the highest increase was in Romania, where initially the RRT prevalence was the lowest. 100% 80% 60% 40% 20% 0% Czeck Rep Polan Hungar Bulgari Romania TR DP HD Mean percentual variation per year Health expend. Total RRT patients were still alive. The main cause of death was cardiovascular disease (74.4%), followed by infections (10.3%), cancer (7.2%), liver diseases (2.6%) and others (5.5%). The estimated overall survival of the patients (Kaplan Meier analysis) was 90.6% at 1 year [confidence interval (CI) ] and 62.2% at 5 years (CI ) (Figure 7). Patients survival was negatively influenced (Cox regression analysis) by age >65 years [hazards ratio (HR) ¼ 2.65, P<0.001], lack of pre-dialysis monitoring by a nephrologist (HR ¼ 1.23, P ¼ 0.01), severe anaemia, lack of erythropoetin treatment (HR ¼ 1.85, P<0.001) and co-morbidity, e.g. cardiovascular diseases and diabetes mellitus (HR ¼ 2.32, P<0.001) (Table 4). 40 Czeck Rep Hungary Poland Bulgaria Romania Fig. 6. Trends in prevalent RRT patients and total health expenditures in selected Central East European countries calculated as mean percentage change per year (1995 vs 2003/2001, first year of observation ¼ 100%). The impressive augmentation in RRT patients in Romania was allowed for by a substantial increase in health expenditures. The opposite is true in the case of Bulgaria. Fig. 5. Trends in renal replacement methods in selected Central East European countries (1995 vs 2003/2001, percentage of total number of patients treated). In Romania, the proportion of patients treated by PD increased by nine times, while in the Czech Republic and Poland, it was the proportion of transplantation patients that doubled. dialysis initiation: the prevalence of cardiovascular diseases and diabetes mellitus doubled in the last 8 years, approaching the levels reported in Western European countries (65 vs 71% and 10 vs 20%) [12], respectively. Survival analysis A total of 2284 patients starting maintenance dialysis between January 1, 1995 and December 31, 2001 in 14 RRT centres and surviving at least 3 months on the initial RRT method were included in the survival analysis. The main characteristics of the patients in the studied cohort are shown in Table 3. At the census point (January 1, 2002), 73.3% (1651) of the enrolled Discussion ESRD incidence and prevalence are increasing worldwide so that required substitutive treatment is currently emerging as one of the difficult challenges for health systems from both developed and developing countries [5,13]. The development and the size of national RRT programmes are variable from country to country, since they have been recognized to be heavily dependent on political, economic and sociocultural conditions. There is a clear direct relationship between Gross National Product (GNP) and availability of RRT [5,14]. An interesting historical perspective is offered by Central and Eastern Europe (CEE), a region where all the above-mentioned factors dramatically changed at the beginning of the last decade of the 20th century, while the epidemiology of renal diseases remained probably comparable with Western Europe/EU countries [14,15]. Fortunately, this change led to a general increase in medical facilities in line with the state of the art of medical knowledge, reflected by several recent reports [1,2,6,16 18].

7 Nephrology and renal replacement therapy in Romania 2977 Table 3. Characteristics of the cohort investigated for survival analysis Table 4. Factors influencing survival (Cox regression analysis for all patients) Overall (n ¼ 164) (n ¼ 398) (n ¼ 2284) Predictive factor (vs reference level) HR 95% CI for HR P-value Demographics Mean age (years) Gender (males %) Primary renal disease Non-diabetic glomerular nephropathies (%) Interstitial nephropathies (%) Hereditary/congenital nephropathies (%) Diabetic nephropathy (%) Vascular nephropathies (%) Others or unknown (%) Co-morbidities Emergency initiation of RRT (%) Diabetes mellitus (%) Cardiovascular diseases (%) Uncontrolled hypertension (%) Left ventricular hypertrophy (%) Ischaemic heart disease (%) Cerebro-vascular diseases (%) Peripheral vascular diseases (%) Pericarditis Hepatitis B/C (%) 16/26 Nephrological follow-up before RRT initiation (%) Vascular access at HD initiation Arterio-venous fistula (%) Central catheter (%) Patient status at RRT initiation Renal function BUN (mean, mg/dl) Serum creatinine (mean, mg/dl) Nutritional status BMI (mean, kg/m 2 ) Serum albumin (mean, g/dl) Anaemia: Hb (mean, g/dl) Fig. 7. Overall survival of RRT patients (n ¼ 2284). Survival chances at: 1 year ¼ 90.6%; 3 years ¼ 74.5%; 5 years ¼ 62.2%; and 7 years ¼ 51.6%. Number of patients alive at: 1 year ¼ 1861; 3 years ¼ 995; 5 years ¼ 425; and 7 years ¼ 55. We are reporting a continuous dramatic development of RRT in Romania in the last 13 years, accelerated from our previous survey [1]. This is in line with general trends observed in CEE countries [6,12,16]. Dialysis development rates in Romania are currently the highest in Europe, so that if these are maintained, as well as the actual survival rate, Gender (male vs female) Age group, years (vs 10 25) to <0.001 Pre-dialysis monitoring (no vs yes) Dialysis modality (PD vs. HD) Hb (<7 vs 7 g/dl) EPO therapy (no vs yes) <0.001 No. of cardiac diseases (vs none) One Two <0.001 Three or more to 4.85 <0.001 Uncontrolled high blood to pressure (yes vs no) Diabetes mellitus (yes vs no) <0.001 Prevalent patients (number) 12,000 10,000 8,000 6,000 4,000 2, ,460 4,200 6,182 4,620 7,019 5,082 7,996 5,590 9,140 6,149 2,520 1,000 1,260 1,588 2, ,486 6,764 3,176 2,003 2,004 2,005 2,006 2,007 2,008 Year HD DP RTx Total Fig. 8. The estimated prevalence of RRT patients in Romania Assuming that the current rates of increase and dropout will remain stable, the actual RRT population will double in the next 5 years. Because 9% of PD patients will switch to HD each year, 950 new HD machines will be necessary in the whole interval, unless there is an increase in the renal transplantation rate. we predict that by 2008 the dialysis population will double again, reaching a tremendous increase from the 400 cases treated before 1989 and a huge financial burden for the health budget (Figure 8). Unfortunately, although dialysis incidence becomes comparable with that of other Eastern or (even) Western European countries, prevalence and, most importantly, resources are still lagging behind. The Romanian Society of Nephrology shares the present view, so clearly synthesized by Schieppati et al. in a recent Kidney International editorial [14], that prevention of the progression of renal disease by implementing a comprehensive screening programme with affordable means and a standardized pharmacological therapeutic strategy should be the most stringent priority for all countries, both developed and developing. In this vein, the focus changed from the previous successful plans for dialysis development 546

8 2978 G. Mircescu et al. to a national programme for Chronic Kidney Disease Prevention, with its first step the implementation of a national survey, similar to the NHANES [19]. A more in-depth analysis of this epidemiological report also reveals some very interesting facts. The overall increase in RRT was boosted by a sustained creation of new HD centres and by (one of) the highest growth of CAPD. Each year the net increase in CAPD was close to þ600% (!). This intensive development was matched by equally favourable outcome measures: CAPD patients survival data are at least comparable with those reported by large registries or by other centres recognized for their excellence in CAPD care. Furthermore, CAPD technique survival and complication rates were also comparable with published literature outcomes [2]. Most importantly, as shown previously [2], these results were not favourably biased by the rescue of particularly ill patients to HD, or by a different inclusion policy compared with HD. This success story scenario is explained by the poor infrastructure and still long travel distances from home to dialysis centres and by the adoption in the large CAPD centres of the integrated care approach first described by Van Biesen et al. [20]. There are important discrepancies in HD facilities from county to county (see Figure 3), and the excellent results of the national CAPD programme created both a last resort philosophy and an enthusiastic tide. We believe that Romania s situation resembles that of the UK in the 1970s and 1980s and, at another scale, that of today s Mexico: the disappearance of unethical restrictions of RRT initiation combined with lower than average resources available nowadays in EU states. Despite the expected failures from CAPD these will represent a huge additional burden, a bomb waiting to explode it is possible that by 2008 PD will represent 30 40% of the overall RRT programme in Romania. Unless backed up by an active transplantation programme, as was the case in the UK, the anticipated overexpansion of PD patient stock will also require an exponential growth of HD centres (950 new HD machines!), with costs difficult to control (Figure 8). In contrast to dialysis development, transplantation is still limited to four centres, mostly from living related donors. In fact, in contrast to Poland and the Czech Republic, the percentage of transplanted patients from the RRT pool actually dropped from 9% in 1996 to 4% in 2003, due to an almost stagnant evolution of this category: þ16% per year. There are two major reasons explaining this particular situation. The lack of a combined and coordinated effort between nephrologists and surgeons adds to the paucity of financial resources both for the development of a true national network for cadaveric organ procurement and for evaluation on a large scale of the potential recipients. Finally, the measures of all successful dialysis therapies are survival reports. To obtain valid results, a large and representative proportion of the national dialysis pool was analysed retrospectively for a 7 year period. One and 5 year survival rates were 91 and 62%, respectively. This is comparable with or superior to large international registry data or other national/ regional registries (EDTA, 82.5 and 47.5%; USRDS, 77 and 31.9%) [18,21]. Age at dialysis initiation is still significantly lower compared with standard current populations in developed countries (53 for HD and 57 for CAPD vs 61 for HD and 64 for CAPD in Italy [22]), as well as the diabetic nephropathy prevalence (8 vs >20% in Western Europe) [10]. However, the range of associated co-morbidities appears to be comparable, supporting the assertion of similar survival rates with large national dialysis databases, and therefore the healthy development of the rapid growth of dialysis facilities in Romania. Also in line with this is the significant increase in the numbers of nephrologists, presently 10 p.m.p., less then in Western Europe, but spending a significant number of hours in the dialysis centre (data not shown). Our study confirms, in a carefully studied large sample size, the negative impact of older age, diabetes, cardiovascular disease and severe anaemia at initiation. Death from cardiovascular causes reached an impressive 74%, significantly higher than that usually reported by registry data (UK Renal Registry, 49%) [23]. We provide further support for the importance of nephrological care and pre-rrt monitoring: 58% of our patients required emergency initiation of dialysis via a central line [14]. Most importantly, the lack of specialized care by a nephrologist was associated with a significant 23% increase in mortality, of which the largest part can be attributed to the lack of anaemia treatment, with a mean pre-rrt haemoglobin level of <8 g/dl. The lack of erythropoetin treatment was associated with an 85% increase in mortality. A limitation of our study is its retrospective nature. To overcome this bias, and also to improve the quality of such data and to provide the basis for further evolution, there is a critical need for regular data acquisition by the national registry and also for prospective collection of individual patient data. In summary, our report reconfirms the spectacular favourable changes seen in Central and Eastern European Countries following the political changes of the 1990s. Romania has one of the highest rates of dialysis development, with good long-term survival results, despite equally significant changes in ESRD epidemiology and co-morbidities at dialysis initiation, pointing to a typical profile of Western European RRT. In particular, the recent (from 1995) onset CAPD programme has the highest rate of increase worldwide, with excellent patient and technique survival. Urgent development of prevention programmes and nationwide transplantation, which currently remains mainly living related on a regional small-scale basis, are required. In order to achieve the transition, incipient institutional changes must be strengthened in Romania, and the nephrological community has to act as a catalyst in this process.

9 Nephrology and renal replacement therapy in Romania 2979 Conclusions In the last decade, major evolution in Romanian nephrology took place, but the transition to CEE standards still continues. Although the rate of increase per year in total RRT patient stock between 1996 and 2003 in Romania was the highest in Europe, the prevalence of RRT patients is still low compared with the European mean. As CAPD was the method with the greatest expansion, followed by HD, this success story could turn to be an unexploded bomb, unless supported by an effective renal transplantation programme. The quality of RRT therapy appears to be good, with good survival rates. Further evolution implies strategies of prevention, based on national surveys and supported by the Romanian Renal Registry. Sustained efforts to increase the role of nephrologists in the medical care of patients in early stages of chronic renal insufficiency and the development of a real national transplantation network should be additional, strategic objectives of the Romanian Society of Nephrology. Acknowledgements. A special thank you goes to Professors V. Tesar and B. Rutkovski who shared with us descriptions of trends in RRT in the Czech Republic and Poland. Romanian Renal Registry: Elena Agapi, Hemodialysis Centre, Fa găras Municipal Hospital; Daniela Anghel, Alba County Hospital; Luminit a Ardeleanu, Floreasca Emergency Clinical Hospital, Bucharest; Mihai Ardeleanu, Suceava County Hospital; Gabriel Bako, Oradea County Hospital; Simona Ba lut ă, Diagnosis and Treatment Medical Center, Bucharest; Aurel Bizo, Cluj Paediatric Dialysis Unit; Ioan Boca, Sibiu County Hospital; Ovidiu Brumariu, Ias i Paediatric Hospital; Viorica Butnaru, Prahova County Hospital; Nicoleta Carastoian, Giurgiu County Hospital; Gheorghe Chiriac-Băbei, Paediatric Clinic, Fundeni Clinical Institute, Bucharest; Alexandru Ciocâlteu, Sf Ioan Clinical Hospital, Bucharest; Cezar Cocerjin, Sa laj County Hospital; Ellisaveta Codos pan, Caras Severin County Hospital; Ion Cret u, Gorj County Hospital; Olimpia Cret u, Teleorman County Hospital, Grigore Dogaru, Mures County Hospital; Dionisie Dubinciuc, Dialysis Centre, Vaˆlcea County Hospital; Hortensia Epure, Haemodialysis Unit, Bras ov Paediatric Hospital; Valentina Georgescu, Chronic Haemodialysis Centre, Arges Diagnosis and Treatment Centre; Adrian Ghenu, Dâmbovit a County Hospital; Ioan Pat iu, Mihai Manasia Clinic of Nephrology, Cluj County Hospital; Eugen Mot a, Dolj County Hospital; Iuliana Grigoras, Dialysis Centre, Bârlad Hospital; Sabina Grigorescu, CF Hospital Ploies ti; Anghel Horia, Wolfgang Steger Haemodialysis Centre, Petros ani Emergency Hospital; Ioana Iacob, Haemodialysis Centre, Vrancea County Hospital; Mariana Iacob, Dialysis Unit, Galat i Paediatric County Hospital; Ion Iancu, Haemodialysis Centre, Constant a County Hospital; Rodica Ilies, Bistrit a Na săud County Hospital; Magdalena Ioan, Dialysis Centre, Buzău County Hospital; Ion Ioan Costică, Dialysis Centre, Bucharest University Hospital; Alexandru Ionit ă, Călăras i County Hospital; Ligia Iosub, Botos ani Mavromati County Hospital; Zsofia Ivacsony, Sankta Maria Haemodialysis Centre, Covasna County Hospital; Cecilia Jitea, Haemodialysis Centre, Tulcea County Hospital; Eminee Kereszy, Urology, Dialysis and Transplant Centre, Fundeni Clinical Institute, Bucharest; Petru Kovary, Oradea County Hospital; Doriana Lucaciu, Haemodialysis Unit, Cluj Napoca Municipal Clinical Hospital; Radu Macavei, Sarah Haemodialysis Centre, Bras ov County Hospital; Adriana Marinescu, Dialysis Unit, Videle Hospital; Sorina Mas ek, Dialysis Unit, Lugoj Municipal Hospital; Florin Mărgineanu, Mehedint i County Hospital; Marilena Micu, Haemodialysis Centre, Satu Mare County Hospital; S tefan Mihăilescu, Bra ila County Hospital; Viorel Iancu Paˆtea, Haemodialysis Centre, Arad Municipal Clinical Hospital; Varga Peter, Harghita County Hospital; Maria Petre, CF Clinical Hospital, Bucharest; Jozsef Pop, Haemodialysis Centre, Odorheiu Secuiesc Municipal Hospital; Mariana Pop, Haemodialysis Centre, Maramures County Hospital; Marcela Pravăt, Haemodialysis Unit, Ialomit a County Hospital; Alecsandru Radu, Haemodialysis Centre, Prof. C. Angelescu Hospital, Bucharest; Monica Radu, Câmpia Turzii Municipal Hospital; Mihai Raicu, Haemodialysis Centre, Deva County Hospital; Eugenia Ra ileanu, Medias Municipal Hospital; Lidia Râjnoveanu, Sinaia Hospital; Leonard Ros u, Bacău County Hospital; Violeta Roman, Nephrology and Dialysis Department, Mures County Hospital; Ioan Sabău, Louis T urcanu Paediatric Hospital, Timis oara; Cristian Serafinceanu, N. C. Paulescu Diabetes, Nutrition and Metabolic Diseases Institute, Bucharest; Aurelian Simionescu, Olt County Hospital; Roxana Stavăr, Sf. Apostol Andrei Galat i County Hospital; Tatiana S uiagă, Hunedoara Municipal Hospital; Carmen Turcea, Haemodialysis Centre, Neamt County Hospital; Coriolan Ulmeanu, Grigore Alexandrescu Paediatric Hospital, Bucharest; Mihai Voiculescu, Nephrology Department, Fundeni Clinical Institute, Bucharest. Conflict of interest statement. None declared. References 1. Ursea N, Mircescu G, Constantinovici N, Verzan C. 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