REGISTRY OF THE NEPHROLOGY, DIALYSIS AND TRANSPLANTATION IN TURKEY

Transkript

1 PUBLISHED BY THE TURKISH SOCIETY OF NEPHROLOGY REGISTRY OF THE NEPHROLOGY, DIALYSIS AND TRANSPLANTATION IN TURKEY REGISTRY 24 Central Registry Committee Ekrem EREK Chairman Gültekin SÜLEYMANLAR General Secretary of Turkish Society of Nephrology Kamil SERDENGEÇTİ President of Turkish Society of Nephrology İstanbul - 25

2 PUBLISHED BY THE TURKISH SOCIETY OF NEPHROLOGY Important Note All copyrights are reserved for Turkish Society of Nephrology. Articles and figures might not be published without reference. Contents and Design: OMEGA Contract Research Organization Printing: Art Ofset Printing date: June 25

3 INTRODUCTION 15 Years in Turkish Nephrology Registry Nephrology, Dialysis and Transplantation studies which are started in 1989 including solely Istanbul, are being performed in country wide since 199 and published by Turkish Society of Nephrology, annually (except 1994). On the following two pages, you might see the names of the books and people who have worked throughout the publishing process. Till 1993 a lot of friends of us have taken place in Central Registry Committee. I am grateful to them. For efforts they spent in communicating with foreign and domestic nephrology centers and for supports in evaluating and commenting the collected data, I especially thankful to Kamil Serdengeçti, President of Turkish Society of Nephrology and to Gültekin Süleymanlar, General Secretary, who are the indispensable and permanent names of our society. Mehmet Rıza Altıparmak and Nurhan Seyahi, two young assistant members of Central Registry Committee have spent too much effort. Many thanks to them and to Lale Sever who has given her best support in evaluation of pediatric nephrology results. Registry studies which were performed with an amateur spirit till three years ago, are being executed by a professional company since 22, under control, support and audition of our Central Registry Committee. You might see the graphics showing the now and then of the Turkish Registry for a period of 15 years. In recent years, Turkish Nephrology Registry has started to take place in two big registries as a result of contribution established with ERA-EDTA and USRDS. For the support they gave to Turkish Nephrology Registry, we are grateful to Kitty Jager, Director of the ERA- EDTA Nephrology Center and to Allan J. Collins, Director of the USRDS Coordinating Center. You might also find the figures of this two big registries and comparative graphics by USRDS, including Turkish results. Turkish Registry of 24 is completed again with the extreme supports of the responsible persons of nephrology, dialysis and transplantation centers. We stated the names of both them and the centers at the back pages of this book. By this means we voice our gratitudes to them. We are also grateful to managers and the staff of Omega Contract Research Organization who have collected the data under the control and support of our Central Registry Committee and prepared the analysis report, and to Fresenius Medical Care, the company that has yet once more sponsored the printing of this book. June 25, Cerrahpaşa, Istanbul Prof. Dr. Ekrem EREK Turkish Society of Nephrology, Chairman to Central Registry Committee Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24 i

4 General Coordinator: TURKISH SOCIETY OF NEPHROLOGY REGISTRY GENERAL COMMITTEE Prof. Dr. Kamil SERDENGEÇTİ President of Turkish Society of Nephrology EDTA-ERA Registry Coordinator for Turkey Assistant Coordinator: Prof. Dr. Gültekin SÜLEYMANLAR General Secretary of Turkish Society of Nephrology Assistant Members to Central Registry Committee: Assoc. Prof. Mehmet Rıza ALTIPARMAK, Dr. Nurhan SEYAHİ Coordinator for Pediatric Nephrology: Prof. Dr. Lale SEVER Regional Coordinators for Ankara and Mid-Turkey: Şali ÇAĞLAR, Mehmet HABERAL, Enver HASANOĞLU, Şükrü SİNDEL, Neval DUMAN, Ayşın BAKKALOĞLU, Oğuz SÖYLEMEZOĞLU, Ayşe ÖNER, Haluk KİPER, Cengiz UTAŞ, Süleyman TÜRK, Necmettin GÜVENCE Regional Coordinators for Istanbul and Thrace Region: Emel AKOĞLU, Mehmet SEVER, Rezzan ATAMAN, Mine BESLER, Funda TÜRKMEN, Uluğ ELDEGEZ, Muzaffer SARIYAR, Saniye ŞEN, Metin ERMAN, Nedim SARSMAZ Hülya Karadayı ERGİN Regional Coordinators for Bursa and Marmara Region: Mustafa YURTKURAN, Kamil DİLEK, Mustafa GÜLLÜLÜ, Nilay OKTAY, Betül KALENDER Regional Coordinators for Izmir and Aegean Region: Ali BAŞÇI, Sevgi MİR, Taner ÇAMSARI, Fehmi AKÇİÇEK Cüneyt HOŞCOŞKUN, Adam USLU Regional Coordinators for Black Sea Region: Tekin AKPOLAT, Nurol ARIK, Şükrü ULUSOY Regional Coordinators for Eastern Turkey: Yılmaz SELÇUK, Reha ERKOÇ Regional Coordinators for Southeastern Turkey: Bünyamin IŞIKOĞLU, Emin YILMAZ, Asım GÖYMEN Regional Coordinators for Adana and Çukurova Region: Yahya SAĞLIKER, Uğur EKREN, Zeki GÜLOĞLU, Saime PAYDAŞ Regional Coordinators for Antalya and Mediterranean Region: Gülşen YAKUPOĞLU, Fevzi ERSOY, Alper DEMİRBAŞ Communication and Assistance in Data Collection: Executive Secretary: Mübeccel AKYÜZ Central Registry Committee Secretary: Şükran AKPINAR Project Management: Omega Contract Research Organization Project Managers: Ebru MUTLU, Hakan YILMAZ Assistant Project Manager Kartal ÇETİNTÜRK Regional Project Managers: Öznur BİÇEROĞLU, Yeşim KOÇ (Ankara), Güliz ÖZGEN (İstanbul), Buket ÜNAK (İzmir), Mesut BAHAR (Samsun) Data Analysis and Reporting: Oktay ÖZDEMİR, Ferit ÜN, Bülent SAKAOĞLU Database Management and Software Development: Berk ÖZDEMİR, Taner SUNDU, Taner VAROL Data Entry Officers: Fatih ELİTOĞ, Emre ÖZKAN Review of Forms: Hakan YILMAZ, Kartal ÇETİNTÜRK, Serpil ÇOBAN Graphics and Translation: Murat KİRTİŞ ii Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24

5 The Registry Books Published in Last 15 Years 1. Today of Hemodialysis in Istanbul, Istanbul 1989 Publishing Committee: Ekrem Erek, Serhat Perk. Publisher: Turkish Society of Nephrology, number of pages: Today of Nephrology, Dialysis and Transplantation in Turkey, 199 Publishing Committee: Ekrem Erek, Serhan Dalmak. Publisher: Turkish Society of Nephrology, number of pages: Nephrology, Dialysis and Transplantation in Turkey, Registry 1991 Publishing Committee: Ekrem Erek, Rezzan Ataman, Serran Dalmak, Süheyla Apaydın. Publisher: Turkish Society of Nephrology, number of pages: Nephrology, Dialysis and Transplantation in Turkey, Registry Publishing Committee: Ekrem Erek, Kamil Serdengeçti, Rezzan Ataman, Süheyla Apaydın. Publisher: Turkish Society of Nephrology, number of pages: Nephrology, Dialysis and Transplantation in Turkey, Registry 1995 Publishing Committee: Ekrem Erek, Gültekin Süleymanlar, Kamil Serdengeçti. Publisher: Turkish Society of Nephrology, number of pages: Nephrology, Dialysis and Transplantation in Turkey, Registry 1996 Publishing Committee: Ekrem Erek, Gültekin Süleymanlar, Kamil Serdengeçti. Publisher: Turkish Society of Nephrology, number of pages: Nephrology, Dialysis and Transplantation in Turkey, Registry 1997 Publishing Committee: Ekrem Erek, Gültekin Süleymanlar, Kamil Serdengeçti. Publisher: Turkish Society of Nephrology, number of pages: Nephrology, Dialysis and Transplantation in Turkey, Registry 1998 Publishing Committee: Ekrem Erek, Gültekin Süleymanlar, Kamil Serdengeçti. Publisher: Turkish Society of Nephrology, number of pages: Nephrology, Dialysis and Transplantation in Turkey, Registry 1999 (including English version) Central Registry Committee: Ekrem Erek, Gültekin Süleymanlar, Kamil Serdengeçti. Publisher: Turkish Society of Nephrology, number of pages: Nephrology, Dialysis and Transplantation in Turkey, Registry 2 (including English version) Central Registry Committee: Ekrem Erek, Gültekin Süleymanlar, Kamil Serdengeçti. Publisher: Turkish Society of Nephrology, number of pages: Nephrology, Dialysis and Transplantation in Turkey, Registry 21 (including English version) Central Registry Committee: Ekrem Erek, Gültekin Süleymanlar, Kamil Serdengeçti. Publisher: Turkish Society of Nephrology, number of pages: Nephrology, Dialysis and Transplantation in Turkey, Registry 22 (including English version) Central Registry Committee: Ekrem Erek, Gültekin Süleymanlar, Kamil Serdengeçti. Publisher: Turkish Society of Nephrology, number of pages: Nephrology, Dialysis and Transplantation in Turkey, Registry 23 (including English version) Central Registry Committee: Ekrem Erek, Gültekin Süleymanlar, Kamil Serdengeçti. Publisher: Turkish Society of Nephrology, number of pages: Nephrology, Dialysis and Transplantation in Turkey, Registry 24 (English) Central Registry Committee: Ekrem Erek, Gültekin Süleymanlar, Kamil Serdengeçti. Publisher: Turkish Society of Nephrology, number of pages: 91. Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24 iii

6 DEMOGRAPHICS OF TURKEY Background : Modern Turkey was founded in 1923 by Kemal ATATÜRK after a war of independence, following the fall of the 62-years-old Ottoman Empire. Under his leadership, the country adopted wide-ranging social, legal, and political reforms. Location : Southeastern Europe and southwestern Asia Area : Total: sq km Population : Age structure : -14 years: 26% (male /female ) years: 67.3% (male /female ) 65 years and over: 6.7% (male /female ) (25 est.) Median age : Total: 27.7 years Population growth rate : 1.8% (25 est.) Life expectancy at birth : Total population: years Male: years Female: years (25 est.) Total fertility rate : 1.94 children born/woman (25 est.) Number of medical faculties : 35 state, 6 private (January 21) Number of physicians : (22) specialists : general practitioners : Number of nurses : 7.27 (42 private) Per capita income : 425 $/year (24) iv Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24

7 CONTENTS Page 24 Registry... 1 Clinical Nephrology... 3 Renal Replacement Therapies... 7 Hemodialysis... 7 Peritoneal Dialysis Renal Transplantation Pediatric Nephrology Pediatric Hemodialysis Pediatric Peritoneal Dialysis Pediatric Renal Transplantation Comparative Figures from World and Turkey Centers Included in the Registry ABBREVIATIONS APD... Automated peritoneal dialysis BP... Blood pressure CAPD... Continuous ambulatory peritoneal dialysis CGN... Chronic glomerulonephritis CRF... Chronic renal failure DM... Diabetes mellitus EPO... Erythropoietin ESRD... End stage renal disease GFR... Glomerular filtration rate HD... Hemodialysis HT... Hypertension PD... Peritoneal dialysis pmp... Per million population RRT... Renal replacement therapy RTx... Renal transplantation TIN... Tubulointerstitial nephritis TSN... Turkish Society of Nephrology Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24 v

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9 24 REGISTRY Number of centers invited to Registry (including pediatric nephrology centers) Number of centers that do not fit Registry inclusion criteria... 9 Number of centers without HD unit... 3 Number of centers where HD units were closed in Number of centers that could not be reached... 1 Number of centers that fit Registry inclusion criteria Number of non-responding centers... 1 Number of responding centers and response rate (97.8%) Number of centers per million population HD centers Number of specialist physicians Number of general practitioners Total number of physicians Number of nurses Number of HD equipments PD centers Number of specialist physicians Number of general practitioners Total number of physicians Number of nurses Pediatric nephrology centers Number of centers invited to Registry Number of responding centers and response rate (1%) Number of centers with HD units Number of centers with PD units... 3 Number of centers where RTx is performed Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24 1

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11 CLINICAL NEPHROLOGY Incident ESRD* patients in 24 Pre-dialysis patients % HD patients % PD patients... 8.% Tx patients % Prevalent ESRD patients, as of the end of 24 Pre-dialysis patients % HD patients % PD patients... 1.% Tx patients % Primary renal diseases in incident ESRD patients in 24 Diabetes mellitus % Hypertensive renal disease % Chronic glomerulonephritis % Other diseases % Etiology unknown % Primary renal diseases in prevalent ESRD patients, as of the end of 24 Diabetes mellitus % Hypertensive renal disease % Chronic glomerulonephritis % Other diseases % Etiology unknown % * GFR less than 15 ml/min for non-diabetic patients and GFR less than 2 ml/min for diabetic patients are accepted as ESRD. Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24 3

12 Response rate by years Percent Treatment modalities in incident RRT patients (24) HD PD Tx Treatment modalities in prevalent RRT patients (24) HD PD Tx 4 Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24

13 Etiology of incident ESRD patients (24) Diabetes mellitus 25.3 Hypertensive renal disease 17.2 Chronic glomerulonephritis 13.4 Urologic disease 5.8 Chronic interstitial nephritis Cystic renal disease Miscellaneous 6.8 Etiology unknown Etiology of prevalent ESRD patients (24) Diabetes mellitus 23.1 Hypertensive renal disease 19.8 Chronic glomerulonephritis 16.3 Urologic disease Cystic renal disease Chronic interstitial nephritis Miscellaneous Etiology unknown Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24 5

14 TRENDS IN CLINICAL NEPHROLOGY BY YEARS RRT patients with diabetic nephropathy by years RRT patients with cystic renal disease by years Discussion Evaluation is performed based on the results provided by 44 centers (number of pediatric nephrology centers: 32). In the year 24, the point prevalence and incidence rates of ESRD treated with RRT are found as 444 pmp and 123 pmp, respectively. There is an increase in both point prevalence and incidence rates as compared to last year. First three etiologic diseases causing chronic renal disease among incident ESRD patients in 24 are found as diabetes mellitus (25.3%), hypertension (17.2%) and chronic glomerulonephritis (13.4%), respectively. First three etiologic diseases causing chronic renal disease among prevalent ESRD patients as of the end of 24 are found as diabetes mellitus (23.1%), hypertension (19.8%) and chronic glomerulonephritis (16.3%), respectively. 6 Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24

15 RENAL REPLACEMENT THERAPIES HEMODIALYSIS Incident regular HD patients in 24 Male % Female % -15 years of age....4% years of age % 2-44 years of age % years of age % years of age % 75+ years of age % Prevalent regular HD patients as of the end of Male % Female % -15 years of age....3% years of age % 2-44 years of age % years of age % years of age % 75+ years of age % Frequency of HD sessions in regular HD patients, as of the end of 24 Once weekly % Twice weekly % Three times weekly % Duration of dialysis in regular HD patients, as of the end of 24-5 years % 6-1 years % years % 16-2 years % 2+ years....2% Number of dialysers consumed in Synthetic % Semi-synthetic % High-flux % Cuprophane % Percentage of regular HD patients with urea reduction rate higher than.65, as of the end of % Percentage of HD centers where urea kinetics model is used in % Kt/V values in regular HD patients, as of the end of 24 < % % % % > % Types of vascular access in regular HD patients, as of the end of 24 AV fistula (native) % Persistent (tunnel) catheter % AV graft (prosthesis) % Miscellaneous % Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24 7

16 AV fistula localization in regular HD patients, as of the end of 24 Forearm 1/3 distal region % Forearm 1/3 mid-region % Arm 1/3 distal % Snuff-box % Femoral....8% Anticoagulation method in regular HD patients, as of the end of 24 Standard heparinization % Low-molecular weight heparinization % Regional heparinization....1% Miscellaneous....9% Hypertension in regular HD patients, as of the end of 24 Hypertensive % BP >14/9 mmhg, on antihypertensive treatment % BP >14/9 mmhg, not on antihypertensive treatment % BP <14/9 mmhg, on antihypertensive treatment % Normotensive (BP <14/9 mmhg, not on antihypertensive treatment) % Cardiovascular diseases in regular HD patients, as of the end of 24 Left ventricular hypertrophy % Coronary heart disease % Heart failure % Arrythmia % Miscellaneous % Percentage of regular HD patients with hypoalbuminemia (less than 3.5 g/dl), as of the end of % Erythropoietin treatment in regular HD patients, as of the end of 24 Percentage of HD patients on erythropoietin treatment % Percentage of HD patients with erythropoietin resistance % Iron treatment in regular HD patients, as of the end of 24 HD patients on iron treatment % Oral iron treatment... 5.% Parenteral iron treatment % Serum intact PTH levels (pg/ml) in regular HD patients, as of the end of 24 < % % % % > % Phosphate-binding treatment in regular HD patients, as of the end of 24 HD patients on phosphate-binding treatment % Calcium acetate % Calcium carbonate % Aluminium hydroxide % Sevelamer... 2.% Miscellaneous....7% Active vitamin D treatment in regular HD patients, as of the end of 24 HD patients on vitamin D treatment % Oral vitamin D treatment % IV vitamin D treatment % 8 Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24

17 Hepatitis serology in regular HD patients, as of the end of 24 HBsAg (+) % Anti-HCV Ab (+) % Both HBsAg and Anti-HCV Ab (+) % Deaths in regular HD patients, in 24 Deaths due to any cause (14.4%) within the first 9 days of dialysis % after 9 days of dialysis % Causes of death Deaths due to cardiovascular causes % Deaths due to cerebrovascular accidents % Deaths due to malignancies % Deaths due to infections % Deaths due to other causes % Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24 9

18 Age distribution of incident regular HD patients (24) Years of age Mean age of incident regular HD patients (24) Years of age 4 2 Male Female Total Age distribution of incident regular HD patients with diabetic nephropathy (24) Years of age 1 Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24

19 Age distribution of prevalent regular HD patients (24) Years of age Age distribution of prevalent regular HD patients with diabetic nephropathy (24) Years of age 9 Frequency of HD sessions in regular HD patients (24) /week 2/week 3/week Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24 11

20 Distribution of dialyser membranes in regular HD patients (24) Synthetic Semisynthetic High-flux Cuprophane Urea Reduction Rate (URR) in regular HD patients (24) >.65 Urea kinetics model usage in HD centers (24) % of centers Yes 62.2 No 12 Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24

21 Kt/V ratios in regular HD patients (24) >1.8 3/week 2/week Types of vascular access in regular HD patients (24) AV fistula (native) Persistent (tunnel) catheter AV graft (prosthesis) Misc. AV fistula localization in regular HD patients (24) Right Left Forearm 1/3 distal region Forearm 1/3 mid region Arm 1/3 distal region Femoral region Snuff-box Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24 13

22 AV fistula localization in regular HD patients (24) Forearm 1/3 distal region Forearm 1/3 mid region Arm 1/3 distal region 8.5 Snuff-box.8 Femoral region Anticoagulation methods used in regular HD patients (24) Standard heparinization 42.5 Low molecular weight heparinization.1.9 Regional heparinization Misc. Blood pressure status in regular HD patients (24) BP <14/9 mmhg untreated BP <14/9 mmhg treated BP >14/9 mmhg untreated BP >14/9 mmhg treated 14 Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24

23 Cardiovascular diseases in regular HD patients (24) Left ventricle hypertrophy 19.3 Heart failure 6.8 Arrythmia Angina pectoris Peripheral arterial disease 2.9 Coronary by-pass surgery Acute myocardial infarction Cerebrovascular accident Coronary angioplasty / stent Pericarditis Infective endocarditis Serum albumin levels in regular HD patients (24) <3.5 g/dl >3.5 g/dl Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24 15

24 Erythropoietin usage in regular HD patients (24) Yes 37.2 No % of centers Regular serum ferritin measurement in HD centers (24) Yes No Iron treatment in regular HD patients (24) Oral Parenteral None 16 Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24

25 Renal bone disease tests performed in HD centers (24) Routine biochemical tests 97.5 Bone X-rays Serum intact parathormone Parathyroid scintigraphy Bone-specific alkaline phosphatase Serum aluminium Serum Vit-D metabolites Deferoxamine test Bone biopsy Serum osteocalcin % of centers Serum intact parathormone levels in regular HD patients (24) < >1 pg/ml Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24 17

26 Phosphorus binding agents used in regular HD patients (24) Calcium acetate 66.7 Calcium carbonate 13.3 Aluminium hydroxide 4.7 Sevelamer 2. Misc..7 None Active vitamin D used in regular HD patients (24) Oral IV None 18 Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24

27 Hepatitis serology in regular HD patients (24) HBsAg (+) Anti-HCV (+) HBsAg (+) and Anti-HCV (+) Duration of dialysis in regular HD patients (24) >2 Years Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24 19

28 Causes of death in regular HD patients (24) Cardiovascular 46.7 Cerebrovascular accident Malignancy Infection 9.7 Hepatic failure 1.9 Pulmonary emboli 1.2 Misc % of total deaths Deaths due to cardiovascular diseases in regular HD patients (24) % of cardiovascular deaths Heart failure Ischemic heart disease 7.2 Arrythmia 2.5 Misc. Discussion Evaluation is performed based on the results provided by 395 hemodialysis (HD) centers. The number of the centers contributed (n: 388), the number of HD equipments (n: 5964), and the number of HD patients (n: 25321) are increased by 13.% compared to last year. The proportion of patients who are 15 years old or younger is.3%. With a percentage of 79.%, HD is the most commonly used RRT method in Turkey. The total number of physicians and nurses are 1138 and 2829, respectively. There are some differences in numbers as compared to the numbers from Ministry of Health. There are several reasons of this: unlike the report of Ministry of Health, this report does not include; o the incident HD patients of 25, o the numbers of died HD patients, o the potential HD patients of the centers newly established their HD equipments. 2 Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24

29 The proportion of diabetic patients among the HD patients is increased from 19.2% to %23. and this fact shows that diabetes mellitus, as a cause of ESRD, has an increasing rate in Turkey as well. The age range of HD patients: 49.8% of all patients and 52.4% of diabetic patients are in the age range of 45 and 64. Frequency of HD sessions: three times weekly for 84.8%, twice weekly for 13.6%, and once weekly for 1.6%. There is an increase in the frequency of 3 sessions/week compared to last year. A total of dialysers are used in 385 centers in the year 24. Decrease in cuprophane usage (1.3%) continues while there is a significant increase in synthetic membrane usage. Synthetic membranes are the most commonly prescribed membranes (54%) in the year 24. High-flux membrane usage is 8.9%. There is an increase in urea kinetics model usage in the evaluation of dialysis sufficiency; it is used by 62.2% of the centers. Urea Reduction Rate is lower than.65 in 68.1% of chronic HD patients. Kt/V is higher than 1.2 in 63.7% of the patients. AV fistula is the vascular access route in 9.1% of HD patients and is opened on left arm with a proportion of over 7%. In 57.1% of the patients, dialysis is continued with the initial AV fistula. In 42.5% of the HD patients, low molecular weight heparine is used for anticoagulation. The frequency of hypertension in HD patients is found as 4.7%. Serum albumin level which is one of the reliable indicators of nutrition is lower than 3.5 g/dl in 12.9% of the HD patients. Results are better as compared to last year. The proportion of the patients whose serum albumin level is higher than 4. g/dl is 33.6%. The frequency of EPO usage in HD patients is 62.8% and there is a decrease when compared to last year. Target HB level (>11 g/dl) is reached in only 58.3% of the patients receiving EPO. EPO resistance is found in 7.7% of HD patients. This figure shows decrease as compared to last year (1.6%). Iron treatment is administered in 58.9% of HD patients (oral: 5.%, parenteral: 53.9%). Routine serum ferritin tests are performed in 79.5% of the centers. Routine biochemical tests (97.5%), bone X-rays (74.7%), and parathyroid scintigraphy (7.2%) are the most commonly used tests for renal bone disease in HD patients. The proportions of patients with ipth level <1 pg/ml and >1 pg/ml are 26.7% and 6.1%, respectively. Calcium acetate (66.7%), calcium carbonate (13.3%), and sevelamer (2.%) are used as phosphorus binding agents in HD patients. There is a decrease in the rates of oral (14.3%) and IV (27%) active vitamin D usage compared to last year. Parathyroidectomy is performed in 226 patients. Venous bicarbonate level test is practiced in only 6.6% of the centers, for acidose follow up. There found no change in the frequency of HBV infection in HD patients compared to last year. The frequency of anti-hcv (+) patients continues to decrease (from 24.6% to 19.3%). Dialysis duration is longer than 6 years in more than 3% of HD patients. 31.% of the HD patients died within the first 3 months, which is same as last year. With a rate of 46.7%, cardiovascular diseases are the most common cause of death in HD patients. Cerebrovascular accident, malignancy and infection come after it, respectively. HD is the most commonly used RRT method in ESRD patients in Turkey (79%). While the number of patients keeps increasing, improvements in HD conditions and efforts to provide a more qualified dialysis are being carried on. Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24 21

30 TRENDS IN REGULAR HEMODIALYSIS THERAPY BY YEARS Number of regular HD patients by years Count Frequency of HD sesions in regular HD patients by years /week 2/week 3/week Types of dialysate used in regular HD patients by years Bicarbonate Acetate 22 Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24

31 Types of vascular access in regular HD patients by years AV fistula Catheter Graft Other Hypoalbuminemia (<3.5 g/dl) in regular HD patients by years Erythropoietin usage in regular HD patients by years Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24 23

32 Erythropoietin resistance in regular HD patients by years Iron treatment in regular HD patients by years Active vitamin D usage in regular HD patients by years Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24

33 Frequency of HBsAg (+) regular HD patients by years Frequency of Anti-HCV (+) regular HD patients by years Deaths due to cardiovascular disease in regular HD patients by years % of total deaths Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24 25

34 Deaths due to cerebrovascular accident in regular HD patients by years % of total deaths Deaths due to infections in regular HD patients by years % of total deaths Deaths due to malignancies in regular HD patients by years % of total deaths Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24

35 Deaths due to hepatic failure in regular HD patients by years % of total deaths Discussion The proportion of regular HD patients is increased by 15-2% in the last 15 years. The increase in the weekly HD sessions is more significant for 3 sessions/week. Hygienic conditions have provided the significant decrease in the percentage of HBsAg (+) regular HD patients through years. The decrease in the proportion of anti-hcv (+) patients can be prevented by hygienic conditions, too. Acetate usage as a dialysate has almost left its place to bicarbonate. In Turkey, the most commonly preferred vascular access route is native AV fistula. Unlike USA the proportion of graft is too small. The percentage of EPO usage has showed no significant change through years, while there is an decrease in vitamin D usage, which is a result of. This decrease is a result of strict follow-up of patients. Hypolbuminemia is decreased to 12.9% in 24. This result is very satisfactory as a matter of nutrition. Decrease in iron treatment is observed through 15 years. Through 15 years there observed no significant change in the percentage of deaths due to cardiovascular, cerebrovascular accident or infection. There is a slight increase in the proportion of deaths due to malignancy. Preventing the factors causing resistance, the frequency of EPO resistance is decreased. Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24 27

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37 PERITONEAL DIALYSIS Incident CAPD patients in Male % Female % -15 years of age % years of age % 2-44 years of age % years of age % years of age % 75+ years of age % Incident APD patients in Male % Female % -15 years of age % years of age % 2-44 years of age % years of age % years of age % 75+ years of age % Prevalent PD patients as of the end of Duration of dialysis in PD patients, as of the end of 24-5 years % 6-1 years % years....5% Hypertension in PD patients, as of the end of 24 Hypertensive % BP >14/9 mmhg, on antihypertensive treatment % BP >14/9 mmhg, not on antihypertensive treatment % BP <14/9 mmhg, on antihypertensive treatment % Normotensive (BP < 14/9 mmhg, not on antihypertensive treatment) % Cardiovascular diseases in PD patients, as of the end of 24 Left ventricular hypertrophy % Coronary heart disease % Heart failure % Arrythmia % Miscellaneous % Percentage of PD patients with hypoalbuminemia (less than 3.5 g/dl), as of the end of % Erythropoietin treatment in PD patients, as of the end of 24 Percentage of PD patients on erythropoietin treatment % Percentage of PD patients with erythropoietin resistance % Iron treatment in PD patients, as of the end of 24 PD patients on iron treatment % Oral iron treatment % Parenteral iron treatment % Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24 29

38 Serum intact PTH levels (pg/ml) in PD patients, as of the end of 24 < % % % % > % Phosphate-binding treatment in PD patients, as of the end of 24 PD patients on phosphate-binding treatment % Calcium acetate % Calcium carbonate... 2.% Aluminium hydroxide % Sevelamer % Miscellaneous % Active vitamin D treatment in PD patients, as of the end of 24 PD patients on vitamin D treatment % Oral vitamin D treatment % IV vitamin D treatment % Hepatitis serology in PD patients, as of the end of 24 HBsAg (+) % Anti-HCV Ab (+) % Both HBsAg and Anti-HCV Ab (+)....7% Complications in PD patients, in 24 Percentage of PD patients who experienced peritonitis % Rate of peritonitis... 1/29.7 months Other complications Hyperlipidemia % Obesity % Hernia % Psychological problems... 6.% Insufficient dialysis % Hyperglycemia % Causes of deaths in PD patients, in 24 Deaths due to cardiovascular causes % Deaths due to infections % Deaths due to cerebrovascular accident % Deaths due to malignancies % Deaths due to other causes % 3 Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24

39 Age distribution of incident CAPD patients (24) Years of age Age distribution of incident APD patients (24) Years of age Mean age of incident PD patients (24) Years of age 4 2 Male Female Total Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24 31

40 Age distribution of incident PD patients with diabetic nephropathy (24) Years of age Blood pressure status in PD patients (24) BP <14/9 mmhg untreated BP <14/9 mmhg treated BP >14/9 mmhg untreated BP >14/9 mmhg treated 32 Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24

41 Cardiovascular diseases in PD patients (24) Left ventricle hypertrophy 12.8 Heart failure Arrythmia Peripheral arterial disease Angina pectoris Cerebrovascular accident Coronary angioplasty / stent Coronary by-pass surgery Infective endocarditis Acute myocardial infarction Pericarditis Serum albumin levels in PD patients (24) <3.5 g/dl >3.5 g/dl Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24 33

42 Complications other than peritonitis in PD patients (24) Hyperlipidemia 23.4 Obesity 8.4 Hernia Psychological problems Insufficient dialysis Drainage dysfunction 4.4 Hyperglycemia Erythropoietin usage in PD patients (24) Yes No 34 Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24

43 Iron treatment in PD patients (24) Oral Parenteral None Serum intact parathormone levels in PD patients (24) < >1 pg/ml Phosphorus binding agents used in PD patients (24) Calcium acetate 56.4 Calcium carbonate 2. Aluminium hydroxide 6.1 Sevelamer 2.5 Misc. 1.2 None Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24 35

44 6 Active vitamin D used in PD patients (24) Oral IV None Hepatitis serology in PD patients (24) HBsAg (+) Anti-HCV (+) HBsAg (+) and Anti-HCV (+) Duration of dialysis in PD patients (24) >15 Years 36 Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24

45 Causes of death in PD patients (24) Cardiovascular 37.1 Infection 17.3 Cerebrovascular accident 8.2 Malignancy 3.3 Pulmonary emboli 2.2 Hepatic failure.5 Misc % of total deaths Deaths due to cardiovascular diseases in PD patients (24) % of cardiovascular deaths Ischemic heart disease Heart failure Arrythmia Misc. Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24 37

46 Discussion Evaluation is performed based on the results provided by 51 centers performing chronic peritoneal dialysis. There are 48 certificated PD nurses working in these centers. There are 2683 CAPD patients and 637 APD patients as of the end of 24. The proportion of pediatric patients in CAPD and APD are 1.9% and 1.5%, respectively. The frequency of peritonitis is found as 29.7 patient-months and there is a significant improvement compared to last year. Hypertension (61.3%) and hyperlipidemia (23.4%) are the most common non-infectious complications. Serum albumin level is lower than 3.5 g/dl in 28.9% of the PD patients. This figure is higher compared to last year. There is no difference in EPO usage (56.7%) in PD patients. Target HB level (<11 g/dl) is reached in only 64.6% of the patients receiving EPO. EPO resistance is found in 8.4% of PD patients. Iron treatment is administered in 59.8% of PD patients (oral: 44.4%, parenteral: 15.4%). Routine serum ferritin tests are performed in 79.5% of the centers. The proportion of patients with ipth level <1 pg/ml and >1 pg/ml are 25.8% and 7.2%, respectively. Calcium acetate (56.4%), calcium carbonate (2%), and sevelamer (2.5%) are used as phosphorus binding agents in PD patients. There is a decrease in the rates of oral (37.8%) and IV (2.4%) active vitamin D usage compared to last year. Parathyroidectomy is performed in 47 PD patients. When compared to last year, there found a decrease in the frequency of HBsAg (+) and Anti-HCV (+) patients; (4.8% and 8.9%, respectively). With a rate of 37.1%, cardiovascular disease is the most common cause of death in PD patients and infections and cerebrovascular accidents come after, respectively. Cause of death ranking is similar to the previous years. 38 Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24

47 TRENDS IN PERITONEAL DIALYSIS THERAPY BY YEARS Number of PD patients by years Count Hypoalbuminemia (<3.5 g/dl) in PD patients by years Erythropoietin usage in PD patients by years Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24 39

48 Erythropoietin resistance in PD patients by years Iron treatment in PD patients by years Active vitamin D usage in PD patients by years Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24

49 Frequency of HBsAg (+) PD patients by years Frequency of Anti-HCV (+) PD patients by years Deaths due to cardiovascular diseases in PD patients by years % of total deaths Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24 41

50 Deaths due to cerebrovascular accident in PD patients by years % of total deaths Deaths due to infections in PD patients by years % of total deaths Deaths due to malignancies in PD patients by years % of total deaths Discussion Starting from 1995 number of the PD patients shows an increasing trend. The increase in the proportion of patients receiving EPO is significant. Cardiovascular diseases are the most significant cause of death for 15 years. The proportion of HBsAg (+) PD patients varies from year to year, while the frequency of anti-hcv (+) PD patients is higher between the years as compared to last 5 years. 42 Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24

51 RENAL TRANSPLANTATION Incident RTx patients in Male % Female % -15 years of age % years of age % 2-44 years of age % years of age % 65+ years of age... none Living donor % Related % Spouse % Non-related % Cadaver % Prevalent RTx patients as of the end of Hypertension in RTx patients, as of the end of 24 Hypertensive % BP >14/9 mmhg, on antihypertensive treatment % BP >14/9 mmhg, not on antihypertensive treatment % BP <14/9 mmhg, on antihypertensive treatment % Normotensive (BP <14/9 mmhg, not on antihypertensive treatment) % Cardiovascular diseases in RTx patients, as of the end of 24 Left ventricular hypertrophy % Coronary heart disease % Arrythmia....9% Heart failure....5% Miscellaneous....7% Hepatitis serology in RTx patients, as of the end of 24 HBsAg (+) % Anti-HCV Ab (+) % Both HBsAg and Anti-HCV Ab (+)....2% Status of the incident RTx patients, as of the end of 24 Functioning graft % Allograft dysfunction % Returned to HD % Died % Causes of graft loss in RTx patients, as of the end of 24 Chronic rejection % Death % Relapse of the primary disease % Acute rejection % Primary non-functioning % Misc % Causes of deaths in RTx patients, in 24 Deaths due to infections % Deaths due to cardiovascular causes % Deaths due to cerebrovascular accident % Deaths due to malignancies % Deaths due to other causes % Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24 43

52 Age distribution of incident RTx patients (24) Years of age Age distribution of incident RTx patients by donor type (24) Living Cadaver Years of age Mean age of incident RTx patients (24) Years of age 2 Male Female Living Cadaver Total 44 Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24

53 Hepatitis serology in RTx patients (24) HBsAg (+) Anti-HCV (+) HBsAg (+) and Anti-HCV (+) Blood pressure status in RTx patients (24) BP <14/9 mmhg untreated 61.2 BP <14/9 mmhg treated 1.1 BP >14/9 mmhg untreated 9.5 BP >14/9 mmhg treated Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24 45

54 Cardiovascular diseases in RTx patients (24) Left ventricle hypertrophy 11. Angina pectoris Arrythmia Coronary angioplasty / stent Heart failure Peripheral arterial disease Acute myocardial infarction Cerebrovascular accident Coronary by-pass surgery Infective endocarditis Status of incident RTx patients (24) Functioning graft 12.6 Allograft dysfunction Returned to HD Died 46 Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24

55 Causes of graft loss in prevalent RTx patients (24) Chronic rejection 48.9 Death 38.4 Relapse of the primary disease 4.7 Acute rejection 4.1 Primary non-functioning 2.8 Misc with graft loss Causes of death in prevalent RTx patients (24) Infection 51.1 Cardiovascular 25.5 Cerebrovascular accident 6.4 Malignancy 4.3 Pulmonary emboli 2.1 Misc % of total deaths Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24 47

56 Discussion Evaluation is performed based on the results provided by 25 centers. The number of the RTx patients on follow up is found as 3395 as of the end of 24. The annual number of RTx is increased by 21.7% (n: 665). The rate of cadaver donation is 27.8%. The rate of RTx patients younger than 15 years old is 4.1%. Living donations were 85.6% from relatives, 12.9% from spouse and 1.5% from non-relatives. The frequency of diabetic nephropathy is 3.6% in RTx patients in 24 and diabetes mellitus is found as comorbidity in.8%. Only 12% of the 25 centers performed pancreas Tx in 24. Synchronous kidney and pancreas Tx is performed in 22 patients. The number of the Tx patients in whom kidney is transplanted first is 1. The number of the centers performing laparoscopic nephrectomy in living donors is 2 (8%). Antibody treatment is preferred for induction therapy in 58.3% (n: 388) of the RTx patients, in 24. In 42.5% of them basiliximab, in 35.3% ATG (horse), in 18.8% daclizumab, and in 3.4% thymoglobulin (rabbit) is administered. Increase in the prescribing of the new immunosuppresive agents (mycophenolate mofetil, tacrolimus, IL-2r monoclonal antibodies) will lead to more selective, efficient and safe treatment protocols. Hypertension is observed in 71.8% of the patients as of the end of 24. Blood pressure is out of control in 9.5% of treated patients. The proportions of HBsAg (+) and Anti-HCV (+) patients are 1.4% and 7.5%, respectively, as of the end of % of the centers are performing RTx to HBsAg (+) patients, while 66.7% performs RTx to anti-hcv (+) patients. These figures are decreased compared to last year. Due to the mortality analysis of the year 24, infections are the most common cause of death (51.1%) and significantly increased compared to last year (34.8%). The most commonly observed infection is sepsis. Cardiovascular diseases, cerebrovascular accident and malignancy come after infections, respectively. Chronic rejection (48.9%) and death (38.4%) are the most common causes of graft loss in 24; there found a significant change compared to last year. Serum creatinin level is <2 mg/dl in 8.3% of the RTx patients while it is >2 mg/dl in 12.6% of them, in 24. The proportion of RTx patients who returned to HD is 3.8%, and 19 patients (3.3%) died. 48 Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24

57 TRENDS IN RENAL TRANSPLANTATION BY YEARS Number of RTx's performed by years Count Distribution of RTx patients due to donor type by years Living Cadaver Frequency of HBsAg (+) RTx patients by years Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24 49

58 Frequency of Anti-HCV (+) RTx patients by years Deaths due to cardiovascular disease in RTx patients by years % of total deaths Deaths due to cerebrovascular accident in RTx patients by years % of total deaths Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24

59 Deaths due to infections in RTx patients by years % of total deaths Deaths due to malignancies in RTx patients by years % of total deaths Discussion The number of RTx patients has increased starting from 1995, it is still too low compared to Europe. We believe that this number will increase with the help of the efforts being spent by Ministry of Health in establishing a better organized Tx system. Through 15 years, there is no significant decrease in the proportion of HBsAg (+) patients while a significant decrease in the frequency of anti-hcv (+) patients is observed. Starting from 2, there observed an increase in the percentage of the deaths due to cardiovascular diseases. Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24 51

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61 PEDIATRIC NEPHROLOGY * Primary renal diseases in incident pediatric RRT patients in (n:174) Congenital urologic anomalies (including vesicoureteral reflux) % Primary glomerulonephritis % Neurogenic bladder % Renal hypoplasia / dysplasia... 4.% Secondary glomerulonephritis % Other diseases % Etiology unknown % * Comments on the results of Pediatric Nephrology, Dialysis and Transplantation are made by Prof. Dr. Lale SEVER (İstanbul University Cerrahpaşa Faculty of Medicine Departmant of Pediatrics Division of Clinical Nephrology) Registry of the Nephrology, Dialysis and Transplantation in Turkey, 24 53