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CKD and RENAL REPLACEMENT THERAPY IN ROMANIA

2013

THE ROMANIAN RENAL REGISTRY


Ministry of Health
Dr Carol Davila Clinical Nephrology Hospital
Calea Griviei nr 4, sector 1
010731 Bucharest
Romania
Phone:
+40 21 3129226
Fax:
+40 21 3129226
E-mail:
cdavilla@rdsnet.ro
Website: under construction
Personnel of the Romanian Renal Registry
Prof Dr Gabriel Mircescu
Dr Liliana Grnea
Technicians: Eugen Podgoreanu, Viorica Ion, Daniela Isar
Registrul Renal Romn
Reference suggestions: Annual Report of The Romanian Renal Registry 2012. Ministry of Health - Clinical Nephrology Hospital
Dr. Carol Davila Bucharest, Romania, 2013

Contents
List of gures ............................................................................................. 4

Territorial distribution of the use of renal replacement therapy methods ... 29

List of tables .............................................................................................. 8

The treatment for the replacement of renal functions in children ......... 32

List of appendices ...................................................................................... 9

Survival of the patients............................................................................ 33

Data source ............................................................................................. 12

Standardized mortality ratio.................................................................... 33

Chronic kidney disease ........................................................................... 13

Survival rates ........................................................................................... 35

Data source ............................................................................................. 13

International comparisons ...................................................................... 36

Denitions ............................................................................................... 13

Incident patients...................................................................................... 36

eGFR categories ....................................................................................... 13

Prevalent patients ................................................................................... 39

Proteinuria categories ............................................................................. 14

Replacement therapy method................................................................. 39

Chronic kidney disease ............................................................................ 14

Survival of the renal replacement therapy patients ................................ 42

Stratication by risk ................................................................................. 15

Dialysis service providers ........................................................................ 43

Comorbidities in CKD............................................................................... 16

Organization and nancing...................................................................... 46

Patients starting renal replacement therapy (incident patients)............. 17

Privatization and the public sector .......................................................... 46

Patients under treatment (prevalent) ..................................................... 19

The ratio between the methods .............................................................. 47

Dialysis patients ....................................................................................... 20

Treatment quality .................................................................................... 48

Hemodialysis patients ............................................................................. 23

Prices of the dialysis services .................................................................. 49

Peritoneal dialysis patients ...................................................................... 24

Conclusions ............................................................................................. 50

Patients treated by other dialysis methods ............................................. 26

Appendices .............................................................................................. 52

Transplant patients .................................................................................. 27

Bibliography............................................................................................. 76

List of igures

Figure 1. Stratiication of CKD partients by renal and cardio-vascular risk according to eGFR and proteinuria categories ................................................................................ 13

Figure 2. The distribution within the eGFR categories (G1-G5) of the Romanian and the NHANES cohort ................................................................................................................ 13
Figure 3. The distribution of the CKD categories within the Romanian and NHANES cohorts ......................................................................................................................................... 14

Figure 4. The distribution within the proteinuria categories in the Romanian and NHANES cohorts........................................................................................................................... 14
Figure 5. The distribution of risk groups in the Romanian and NHANES cohorts .................................................................................................................................................................. 15

Figure 6. The prevalence of the main comorbidities requiring hospital admittance (CKD Chronic kidney disease, DM diabetes mellitus) ......................................... 16
Figure 7. Number of patients treated by hemodialysis (HD), peritoneal dialysis (PD) and renal transplantation (RTx) in 2012 and 2013 in Romania ........................ 19
Figure 8. Estimated number of RRT patients in Romania (per million inhabitants).............................................................................................................................................................. 19

Figura 9. Prevalent dialysis patients in Romania (numbers, 1995-2013) .................................................................................................................................................................................. 20

Figure 10. The rate of increase in prevalent dialysis patients in Romania (2009-2012; in percentage as compared to the previous year)................................................. 20

Figure 11. Dialysis patients in Romania (2004-2013) and in Europe (2010) (per million inhabitants - pmi)........................................................................................................... 21
Figure 12. Estimated trends in prevalent patients number and in the rate of increase (percent of the previous year) in Romania 2009-2015 ....................................... 21

Figure 13. Estimated prevalence and incidence of dialysis patients in Romania (pmi - per million inhabitants) .................................................................................................... 22

Figure 14. Estimated number of incident and prevalent hemodialysis (HD) patients in Romania.................................................................................................................................. 23

Figure 15. Estimation of prevalent peritoneal dialysis (PD) patients number in Romania................................................................................................................................................24

Figure 16. The proportions of patients treated by peritoneal dialysis (PD) and of those treated by private dialysis providers in Romania ...............................................24

Figure 17. Trends in dialysis methods usage in Romania (incident patients; HD hemodialysis; DP peritoneal dialysis) ..............................................................................25
Figure 18. The proportions of patients treated by various RRT methods in Romania (prevalent patients on 31.12.2012; N=10,470; prevalent patients on
31.12.2013; N=11,169; DPA automated peritoneal dialysis; DPCA continuous peritoneal dialysis; HDF hemodiailtration; HD- hemodialysis) ...........................26
Figure 19. Incident patients on day 1 in renal replacement therapy in the period 2007-2015 and the percentage of non-preemptive transplant patients) .............27

Figure 20. Origin of kidney grafts for non-preemptive transplantation in 2013 and 2014 ................................................................................................................................................27

Figure 21. Rate of variation (2013/2014; %) in RRT prevalent patients number ..................................................................................................................................................................28
Figure 22. Distribution of dialysis patients in Romania at 31.12.2012 (up) and 31.12.2011 (down). The counties having within both years the lowest
prevalence rates in the country have been highlighted. Data are expressed in number of patients treated per million inhabitants (pmi).
The color scale is deined by the national median and by the quartiles. .....................................................................................................................................................................................29

Figure 23. Dialysis prevalent and incident patients (per 1 million inhabitants) in Romanian counties (in descending order) .........................................................................30
Figure 24. The distribution of incident patients in peritoneal dialysis (PD - up) and in non-preemptive renal transplantation (RTx - down).
The renal transplantation centers and the areas prescribing RTx and HD (blue), PD and HD (green) and exclusively HD (red) are highlighted. ....................................31

Figure 25. Standardized mortality ratio (SMR) in hemodialysis patients by provider (2012) ..........................................................................................................................................33
Figure 26. Standardized mortality ratio (SMR) in hemodialysis patients by provider (2013) ..........................................................................................................................................33
Figure 27. Cumulative survival rated of patients starting renal transplantation (TR), hemodialysis (HD) or peritoneal dialysis (DD)
in 2008-2011 in Romania.................................................................................................................................................................................................................................................................................35
Figure 28. Incident RRT patients in the Europe in 2011 (EDTA-ERA Registry 2011) ...........................................................................................................................................................36

Figure 29. The proportion of RRT incident patients with ages above 65 years of age in Romania (RRR, USA (USRDS) and Europe (EDTA-ERA Registry).................36

Figure 30. Incident RRT patients in 2011 (pmi) (international comparison) ...........................................................................................................................................................................37

Figure 31. Variation 2011/2006 (%) in incident RRT patients number (pmi) (international comparison) ...............................................................................................................37
Figure 32. The proportion of diabetic patients incident in RRT in 2011 (international comparison). ..........................................................................................................................38
Figure 33. Variation 2011/2006 (%) of the proportion of diabetic patients incident in RRT (international comparison)..................................................................................38
Figure 34. The proportions (%) of prevalent patients treated by hemodialysis (HD), peritoneal dialysis (DP) and
renal transplantation (TR) in Europe and Romania .............................................................................................................................................................................................................................39
Figure 35. The proportions (%) of incident patients treated by hemodialysis (HD), peritoneal dialysis (DP) and
renal transplantation (TR) in Europe and Romania .............................................................................................................................................................................................................................39

Figure 36. Patients prevalent on RRT at 31st of December 2011 (pmi) (international comparison) NB. In 2013, in Romania
there were 732 patients treated pmi...........................................................................................................................................................................................................................................................40
Figure 37. Variation 2011/2006 (%) in number prevalent patients undergoing RRT (international comparison) ................................................................................................40
Figure 38. Variation 2011/2006 (%) in prevalent RRT patients number in Europe and in Romania
(HD hemodialysis; DP peritoneal dialysis; TR renal transplantation) ...............................................................................................................................................................................41

Figure 39. Trends of the use of renal replacement therapy methods in Europe and in Romania (variance 2011/2006, in percentage).......................................................41
Figure 40. Unadjusted survival rates of incident dialysis patients in the period 2006-2010 in Europe (EDTA-ERA)
and in Romania (all differences are signiicant).....................................................................................................................................................................................................................................42

Figure 41. The ratio of the dialysis service providers on 31.12.2013 (percentage from the total number of prevalent patients) ....................................................................43
Figure 42. Variation in prevalent patients number 2013/2013 (%) by dialysis service provider..................................................................................................................................43

Figure 43. The proportion of dialysis patients treated in the public sector (%) ......................................................................................................................................................................44

Figure 44. The proportion of PD patients by dialysis providers (percentage of the total number of dialysis patients) .......................................................................................44

Figure 45. The trends in peritoneal dialysis usage by dialysis providers in Romania (PD prevalent patients 2012/2006 in percentage) ...................................................45
Figure 46. Dialysis centers in Romania (2004-2012) ..........................................................................................................................................................................................................................46
Figure 47. The number of patients beneiting from the dialysis program, the program budget (hundreds of thousands of RON) and the costs per patient
(Euro, at the reference NBR currency exchange rate for that year)...............................................................................................................................................................................................46
Figure 48. RRT methods in Romania (2012) and in Europe (EDTA-ERA). Estimated costs of the replacement therapy for one patient/year
(HD hemodialysis, DP peritoneal dialysis; TR renal transplantation)................................................................................................................................................................................47

Figure 49. Modeling the economic impact of the use of PD in 20% of the incident patients (Model DP) compared to the current situation
(over 80% hemodialysis Model HD) and the increase of renal transplantations to 30% (Model TR). Five years after the introduction
of the PD model, the estimated savings compared to the current situation would allow including all incident patients without an increase in the budget. .............47

List of tables
Table I. Prevalence of CKD within the adult population of Romania

14

Table II. Estimation regarding the prevalence of CKD risk groups within the adult population of Romania

15

Table III. Comorbidities requiring hospital admittance

16

Table IV. Characteristics of the incident patients of the 1st day of dialysis within the period 2007-2013

17

TableV. Characteristics of non-preemeptive transplant patients in 2013

17

Table VI. The rst 15 centers by the number of newly included hemodialysis patients

18

Table VII. The rst 15 centers by the number of newly included peritoneal dialysis patients

18

Table VIII. Ways of prescribing renal replacement therapy methods in the counties of Romania (2012)

31

Table IX. Dialysis treatment in children in the period 2007-2013

32

TableX. Adjusted* survival rates (%) by renal replacement therapy methods

35

Table XI. Factors determining the survival of the patients treated by renal replacement therapy methods

35

Table XII. Unadjusted survival rate at 90 days, 1 year and 2 years for the cohort 2006-2010, incident dialysis patients in Europe and Romania

42

Table XIII. Dialysis centers, prevalent patients by provider in Romania (2012/2011)

43

Table XIV. Weighted inuences on the expenses of the Program for dialysis renal replacement

49

Table XV. The characteristics of the patients investigated for the survival analysis

53

List of appendices
Appendix 1. The method for the calculation of the standardized mortality ratio .......................................................................................................................... 52
Appendix 2. The method for the calculation of the survival rates .................................................................................................................................................. 53
Appendix 3. Dialysis centers, machines and patients treated on a machine in the counties of Romania in 2012, 2013 and variance 2013/2012
(in percentage) ................................................................................................................................................................................................................................. 54
Appendix 4. Dialysis patients registered on 31.12.2012 and 31.12.2013 in the counties of Romania and the variance 2013/2012 (in percentage) ................. 56
Appendix 5. Patients newly-included in the haemodialysis (HD), peritoneal dialysis (PD), non-preemptive renal transplantation (RT) and
the number of deaths in 2013 in the counties of Romania ............................................................................................................................................................ 58
Appendix 6. Prevalent patients in the dialysis centers in Romania on 31.12.2011 vs. 31.12.2010 and the variance 2012/2011 in percentage
(in the alphabetical order of the counties)...................................................................................................................................................................................... 60
Appendix 7. Prevalent and incident dialysis patients, non-preemptive transplanted or deceased patients in dialysis centers in Romania in 2013
(in the alphabetical order of the counties)...................................................................................................................................................................................... 66
Appendix 8. Haemodialysis centers ordered increasingly by the standardized mortality ratio (SMR) .......................................................................................... 71

Acknowledgements
Physicians
1.
Turkes Ablachim
2.
Constana Andone
3.
Carina Daniela Andrei
4.
Mihaela Anghel
5.
Daniela Anghel
6.
Carmen Elena Anton
7.
Luminia Ardelean
8.
Mihai Ardeleanu
9.
Gabriel Bako
10.
Mihaela Blgradean
11.
Anca Barbu
12.
Cezarina Bejan
13.
Marilena Tetic
14.
Aurel Bizo
15.
Anca Blaga
16.
Ioan Boca
17.
Eniko Bodurian
18.
Gheorghe Boan
19.
Lavinia Brtescu
20.
Constantin Bulancea
21.
Mirinela Buruian
22.
Viorica Butnaru
23.
Maia Caraman
24.
Nicoleta Carastoian
25.
Cecilia Jitea
26.
Adela Chindri
27.
Bogdan Cmpineanu
28.
Iuliana Ciocnea
29.
Daniela Ciortea
30.
Cezar Lucian Cocerjin
31.
Elisaveta Codopan
32.
Adrian Covic
33.
Maria Covic
34.
Olimpia Creu

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Constantin Cruceru
Luminia Damian
Dionisie Dubinciuc
Sergiu Dumitrache
Hortensia Viorica Epure
Lidia Florescu
Gabriela Maria Fociuc
Nicoleta Irina Foc
Valentina Georgescu
Ivona Georgescu
Adrian Ghenu
Mirela Gherman Cprioar
Mirela Liana Gliga
Ovidiu Golea
Sabina Grigorescu
Monica Simona Heeganu
Mariana Iacob
Ioana Iacob
Ion Iancu
Rodica Ilie
Ligia Iosub
Zsoa Rozalia Ivacson
Christian Klein
Raluca Ungureanu Lie
Doriana Lucaciu
Radu Macavei
Florin Mrgineanu
Simona Marian
Adriana Marinescu
Ioana Diana Mari
Beatrice Marusceac
Sorina Masek
Marilena Micu
Ileana Mihilescu

69.
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Eugen Moa
Dan Munteanu
Mihaela Munteanu
Ioana Nicoleta Nicolae
Marcel Palamar
Radu Viorel Ptea
Ioan Mihai Paiu
Marilena Piper
Mariana Pop
Luminia Popa
Marcela Prav
Daniela Pricop
Monica Radu
Mihai Raicu
Eugenia Rilean
Violeta Roman
Leonard Rou
Mihaela Rou
Cornel Rusan
Oana Schiller
Cristian Seranceanu
Aurelian Simionescu
Petronela odolescu
Costel Spnu
Roxana Dorina Stavr
Ioana Suciu
Dorina Tacu
Ctlin Tacu
Mircea andru
Cristina Teodoru
Delia Timofte
Daniela Elena Tir
Camelia Totolici
Carmen Turcea

103.
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Liliana Tu
Cristina Vduva
Peter Varga
Mariana Vasilescu
Adina Monica Vere
Gabriela Voicu
Mihai Voiculescu
Carmen Volov
Diana Ziliteanu
Adrian Zugravu
Radu Drgulete
Adriana Buhai
Tatiana uiaga
Mirela Modlc
Cristiana David
Elena Blatu
Claudia Cusai
Ana Maria Dominte
Suzana Anca Berca
Diana Copceanu
Andreea Costea
Mihaela Iavorenciuc
Carmen Denise Cldraru
Adrian-Bogdan Ghigolea
Oana Sklerniacof

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Persons in charge with the relationship with RRR


1.
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34.

Cati Aurschioaie
Gaspar Balazs
Zoltan Barabas
Mariana Becheanu
Mirela Beldean
Mihaela Beldiman
Marcela Berar
Mariana Brsan
Istvan Blenyesi
Georgeta Blidariu
Ilie Blotor
Marian Boboc
Maria Boeru
Cristiana Bojica
Adrian Bosie
Marin Braoveanu
Ioana Breaza
Ana Maria Igna
Cristina Bursuc
Narcis Buturug
Otilia Carteleanu
Nicoleta Stoica
Veronica Clin
Cipriana Chereche
Beniamin Chifor
Ionela Chirigiu
Teodora Condriuc
Romulus Corban
Lucian Costchescu
Valerica Crmaru
Georgiana Cutochera
Loredana Danciu
George Dnil
Stela Dnulescu

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67.

Doru Deju
Adrian Dobrioiu
Olga Dragula
Gina Dumbrav
Elena Durubal
Camelia Epure
Mirela Faur
Livia Flore
Emilian Floroaia
Margareta Grdil
Gabriela Ioni
Delia Iordache
Elena Lazr
Elena Lulciuc
Sergiu Lupulescu
Anca Maczo
Gabriela Maftei
Aurel Marian
Elena Marin
Sorina Matei
Amalia Mihance
Paula Mndreanu
Elena Munteanu
Sanda Nica
Luminia Niu
Mirela Olaru
Monica Olroiu
Rducu Olteanu
Claudiu Oetea
Elena Pais
Ionela Palade
Ionela Pascal
Irina Pert

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Monica Crciun
Florentina Petrescu
Oana Petru
Tania Cmpeanu
Adriana Ploscar
Veronica Plotenaru
Dana Poborena
Marius Popoac
Melania Prioteasa
Anca Pucerea
Maricica Radu
Carmen Raicu
Liliana Rcoreanu
Monica Rodina
Mdlina Rugin
Anca Rusu
Angelica Sandu
Maria Savu
Ioan Schink
Florentina Sebacher
Bianca Semeniuc
Dorina Serciu
Roxana Seserman
Laura Slabinschi
tefania Stnescu
Doina Stng
Monica Stoica
Elena Stoina
Zoe Stroe
Cristian Stupinean
Monica Suciu
Liliana erban
Armand tefnescu

101.
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Angela tirbu
Mdlina Tene
Ioana Tipa
Cristina Toac
Carmen Tonia
Erika Trif
Lenua Tuc
Daniela Tudor
Lucian Tudora
Georgeta Turc
Constantin Vldescu
Elena Voiculescu
Francisc Zabos
Mihaela Zaraza
Georgeta Cristina Ni
Eugenia Naftan
Cristina Tutuianu
Elena Ilie
Emilia Chifor
Alina Blc
Cristina Zamora
Nicoleta Huzum
Gabriela Moise
Dana Sabie
Adriana Cerceaun
Elena Anastasiu
Daniela Du
Diana Mocanu
Violeta Gabor
Camelia endroiu
Andreea Boan

11

Data source

REPORT ON THE RENAL REPLACEMENT


THERAPY IN ROMANIA 2013

The report regarding the situation of renal replacement therapy in Romania is based on the data gathered on-line by the Romanian Renal Registry using the
Hipocrate IT system, with the participation of 97% of the existing dialysis centers in 2013.
The data regarding the kidney transplantation in incident dialysis patients are received from the dialysis centers, while the data regarding the pre-emptive
kidney transplantation and the monitoring of the prevalent kidney transplant patients are provided by a single transplantation center from the four existing
centers. The number of prevalent transplant patients on 31.12.2012 and 2013 was provided by the National Health Insurance House.
Epidemiology of Chronic kidney disease was evaluated using data collected in the Romanian Ministry of Health Program of Health Status Evalution in a cohort
from Iassy county. The new analyses complete the already published data1,2,3.

12

Chronic kidney disease


Data source
The database created during the Program of Health
Status evaluation (2007-2008) in the Iai county
contained information on 176,586 subjects. Data on
serum creatinine and the proteinuria were available
for 32,174 subjects. After excluding participants with
age below 21 years, the nal population analyzed
included 30,068 adults (17% of the evaluated subjects,
4% of the county population).

Deinitions
CKD diagnosis, eGFR and proteinuria categories and
the stratication by risk were dened according to
KDIGO 20124 (Figure 1). Because proteinuria was
qualitatively measured using strips or quantitatively,
the results were converted in A1-A3 risk categories
as described by KDIGO, and the eGFR was estimated
based on serum creatinine level and CKD-EPI formula.

>90mL/min
89-60mL/min
45-59/mL/min
44-30mL/min
29-15mL/min
<15mL/min

G1
G2
G3a
eGFR categories
G3b
G4
G5
Risk
Minimum
Low
Moderate
High

A1
<30mg/day
Absent

Proteinuria categories
A2
30 300mg/day
1+

A3
>300mg/day
>1+

Figure 1. Stratication of CKD partients by renal and cardio-vascular risk according to eGFR
and proteinuria categories
70%
6 0%
50%

eGFR categories

4 0%

The prevalence of G3-G5 CKD stages was lower in


the NHANES cohort than in the adult population of
Romania. The prevalence of persons in G1 was lower,
but higher in G2 and G3a categories, in Romania as
compared to USA. These dierences are probably due
to the higher prevalence of diabetes in the USA and
to a selection bias in the Iai cohort, where seems
that especially patients with comorbidities came for
evaluation (Figure 2).

30%

57.9 %
4 5.3%

4 5.1%
35.4 %

NHANES
Ro

20%
10%
0%

4 .6 %
G1

G2

7.7%

G3a

6 .7%
1.6 % 1.6 % 0.4 %
G3b

0.2%
G4

9 .7%

0.1% 0.1%
G5

G3-G5

Figure 2. The distribution within the eGFR categories (G1-G5) of the Romanian
and the NHANES cohort

13

Proteinuria categories

100%

The distribution within the proteinuria categories was almost


numerical equal in NHANES and Romanian cohorts (Figure 3).

9 3, 2%

80%
6 0%

Chronic kidney disease

NHANES
Ro

4 0%

CKD (dened as albuminuria above 30mg/g - A2 or eGFR below


60mL/min -G2+) prevalence in Romania was 13.1%, comparable
to reports in the NHANES cohort (11.5%) (Figure 4).

20%

5, 4 %

0%

By extrapolation to the entire adult population of Romania,


about 1,900,000 persons are aected by Chronic kidney
disease, from which 275,000 would require specialized
nephrology care (stages 3b-5). (Table I).

A1

4 , 0%

1, 1%

1, 3%

A2

A3

Figure 4. The distribution within the proteinuria categories in


the Romanian and NHANES cohorts

Table I. CKD prevalence CKD in the adult population of Romania

CKD category
Percentage
Number
G1 + A2-A3
0.7%
101.200
G2 + A2-A3
2.8%
404.801
G3a
7.7%
1,113,202
G3b
1.6%
231.315
G4
0.2%
28.914
G5
0.1%
14.457
Total CKD
13.1%
1,893,889
On May 31st 2014 the population of Romania was
of 19,631,292, and the population above 24 years
of age reached to 14,457,168 inhabitants (INS)

9 4 ,9 %

14 %
11, 5%

12%

13, 1%

10%
7, 7%

8%

6 %
4 %
2%
0%

NHANES

4 ,6 %
2, 5%

2, 3%
0, 7%

RO

2, 8%
1, 6 %

1, 6 %

0, 4 %

0, 2%

0, 1%

0, 1%

Figure 3. The distribution of the CKD categories within the Romanian and NHANES cohorts

14

NHANES
NHANES

57.9
57.9
34.5
34.5
3.6

G1

Stratiication by risk
Although the distribution by eGFR and albuminuria
categories diered, there were no major dierences
in the distribution of the two cohorts in the risk groups
(Figure 3).

3.6
G1 G2
1.0
G2 G3a
1.0
G3a G3b
G3b G4
G4

0.2
0.2
G5

0.1
0.1

G5

A1
A1

Table II. The estimated prevalence of CKD risk groups within


the Romanian adult population
CKD category

Percentage

Number

Minimum risk

86.9%

12,468,609

Low risk

9.2%

1,316,303

Medium risk

3.0%

437,177

High risk

0.9%

128,385

On May 31st 2014 the population of Romania was of


19,631,292, and the population above 24 years of age
reached to 10,490,197 inhabitants

Thus, almost 500,000 Romanian are at medium and


high risk and should be cared by the existing 300
nephrologists.

15%
15%
10%

A2
A2

A3
A3

Romnia
Romnia

45.1%

45.1% 45.3%
45.3%

10%
5%

6.5%

5%
0%
G1
0%
G1 G2

G2 G3a
G3a G3b
G3b

6.5%
1.3%
1.3%
G4
G4

0.2%
0.2% 0.1%

G5
G5

0.1%
A1
A1

A2
A2

A3
A3

Figure 5. The distribution of risk groups in the Romanian and NHANES cohorts

15

Comorbidities and CKD


The main comorbidities imposing hospital admission
were HBP, heart failure and diabetes mellitus. Stroke, as
well as death, were twice more common in CKD than in
non-CKD persons (Table III).
The need of hospital admission seemed to be less
inuenced by the CKD, even though the average number
of admissions was lower in CKD (Table III).
Figure 6. The prevalence of the main comorbidities requiring hospital
admittance (CKD Chronic kidney disease, DM diabetes mellitus)

Table III. Comorbidities imposing hospital admission


CKD

Non-CKD

6.4

10.5

HBP

46.1%

29.3%

Heart failure

19.3%

11.1%

Stroke

8.6%

4.3%

Ischemic heart disease

7.5%

4.2%

Deaths (for 100 persons-years)

1.41

0.70

Hospital admissions
(for 100 persons-years)
Comorbidity (% admittances)

According to causes of admission, the estimated


prevalence of diabetes mellitus, cardiovascular diseases,
and CKD were 9%, 30% and 10%, respecttively. All these
pathology categories were strongly related (Figure 6).

The Chronic kidney disease has a higher prevalence in Romania that in the
NHANES cohort: 13.1% vs. 11.5%; the estimated number of adult persons
with CKD in Romania is about 1,900,000.

Since the number of CKD patients with medium-high risk is 565,000, a


nephrologist should have under care 1,900 patients
(approximately 20 visits/day).

CKD patients suer more often from diabetes mellitus, HBP, stroke and heart
failure, and their risk of death is twice higher. As a result, the CKD care should
be multidisciplinary (diabetology, cardiology and nephrology).

The medical assistance is mainly provided in hospital (over a quarter of the


pa-tients are admitted into hospital), regardless of the state of the kidney,
and the CKD patients have almost twice as many hospital admittances.

Thus, multidisciplinary CKD medical care programs promoting ambulatory


care are needed.
16

Table IV. Characteristics of incident patients in the 1st day of dialysis within the period 2007-2013
2007

2008

2009

2010

2011

2012

2013

75

85

102

131

148*

137*

138*

100

100

98

90

92

96

97

Number

1,910

2,036

2,377

2,662

2,987

3,428

3,063

Sex (B%)

58.8

57.8

57.7

57.5

57.6

57.8

56.7

Average age (years)

58.1

58,.3

60.5

61.2

62.0

62.6

62.6

34

37

39

39

41

43

42

Glomerulonephritis (%)

17.1

16.2

13.5

13.9

13.6

13.7

12.6

Interstitial nephritis (%)

12.4

11.5

11.4

11.2

11.3

11.3

10.0

Hereditary-congenital
nephropathies (%)

5.7

5.8

5.1

4.6

5.3

6.6

4.4

Diabetes mellitus (%)

11.7

19.9

18.7

13.3

14.8

15.7

14.7

6.5

11.8

6.2

6.3

14.5

15.4

9.9

Other (%)

15.5

9.4

6.4

7.4

5.5

6.4

10.7

Unknown (%)

31.1

25.4

38.7

43.3

35.0

30.9

37.7

Centers (number)
Reporting centers (%)

Incident RRT patients


Dialysis incident patients were mainly men, with
a mean age of 62.6 years (42% above 65 years).
The most frequent primary kidney disease was
diabetic nephropathy (14.7%), but in more than
a third of patients (37.7%) the primary renal
disease was not known. This high proportion
of undiagnosed cases highlights the late CKD
identication imposing emergency dialysis
initiation (Table IV).
Non-preemptive transplanted patients are mostly
men and are younger than incident dialysis
patients. The most frequent primary kidney
disease was glomerulonephritis (45.9%) and
was unknown in more than a third of the cases
(36.2%) (Table V).

Incident patients day 1

65 years (%)
Primary kidney disease

Kidney vascular disease (%)

Replacement therapy method at the beginning


HD (%)

82.3

82.0

83.6

93.5

93.8

95.1

95.0

DP (%)

17.7

18.0

16.4

6.5

6.2

4.9

5.0

Table V. Characteristics of incident non-preemeptive transplant patients in 2013

The incident patients characteristics are


changing: the proportion of the diabetic
patients above 65 years is increasing (42%
and 15%), which would imply additional
resources for care.
As there are no ecient programs addressing
CKD before the renal replacement therapy
initiation, the dialysis is initiated under
emergency condition with higher morbidity
and mortality rates and higher costs, and
primary renal disease is barely diagnosed.

Sex (B%)

67.9

Age
average (years)

42.1

65 years (%)

1.4

Primary kidney disease


Glomerular nephritis (%)

45.9

Interstitial nephritis (%)

2.8

Hereditary-congenital (%)

5.1

Diabetes (%)

2.2

Renal vascular diseases (%)

2.8

Other (%)

5.0

Unknown (%)

36.2

17

Table VI. The rst 15 centers by the number of newly


included hemodialysis patients
Center
Dr. C. I. Parhon Clinical Hospital Iasi

Most of incident patients were included in


the hospital centers (CI Parhon Iai, Dr
Carol Davila and the University Emergency
Hospital Bucharest for hemodialysis, and
Dr Carol Davila, Fundeni Institute and Sf
Apostol Andrei Galai, for peritoneal dialysis)
(Tabelul VI, Tabelul VII).

Newlyincluded
patients

261

Table VII. The rst 15 centers by the number of newly


included peritoneal dialysis patients
Center
Dr. Carol Davila Clinical Nephrology
Hospital Bucharest
Fundeni Clinical Institute

Newlyincluded
patients

16

Dr. Carol Davila Clinical Nephrology Hospital Bucharest


University Emergency Hospital Bucharest

172
133

Sf. Ap. Andrei County Hospital - Galati

12

Sf. Ioan cel Nou County Hospital Suceava

132

IHS - Buzau

10

Sf. Ioan Clinical Hospital Bucharest

110

Bacau County Hospital

10

Craiova County Emergency Hospital

103

14

Braila County Hospital

Constanta County Emergency Hospital

92

Craiova County Hospital

Cluj County Hospital

76

Renamed Nefrodial - Oradea

Arad County Hospital

74

N. Paulescu Institute Bucharest

Prahova County Hospital

67

Fresenius NephroCare - CI Parhon Iasi

Sibiu County Hospital

67

IHS Sf. Ioan Bucharest

Timis County Hospital

62

IHS - Ramnicu Valcea

Brasov County Emergency Hospital

61

University Emergency Hospital Bucharest

Dambovita County Hospital Targoviste

61

Teleorman County Hospital Alexandria

Hunedoara County - Deva

56

Sf. Pantelimon County Hospital - Focsani

Total
1.527*
* 58% of total number of newly included patients

Total

107*

*69% of total number of newly included patients

18

12, 000

+ 8%
10, 322
9 , 551

10, 000
8, 000

2012

6 , 000
4 , 000

The total number of patients undergoing renal


replacement therapy on 31.12.2013 was 13,899,
an 8% increase compared to the year 2012. The
increase was especially caused by transplant
(+11%) and the hemodialysis patients (+8%), while
peritoneal dialysis decreased by 7% (Figure 7).
The number of RRT patients per million inhabitants
reached to 732, increasing, but still below the
European average from 2012 (947 RRT patients per
million inhabitants) (Figure 8). If the current trends
are maintained, Romania will reach the average
European level of RRT coverage in 2016, when the
rate of increase in patient number it is expected to
decrease.

Renal replacement therapy coverage in


Romania approaches the European average
that it shall reach in 2016.

2, 4 57 2, 723

- 7%

2, 000

9 19

HD

854
DP

RTx

Figure 7. Number of patients treated by hemodialysis (HD), peritoneal dialysis


(PD) and renal transplantation (RTx) in 2012 and 2013 in Romania
14 00
RRT patients per million population

Patients under treatment (prevalent)

2013

+ 11%

119 6

1200
1000
800

889
6 80

9 4 0

9 9 1

104 2

109 4

ED TA- ERA 2012

732

6 00
4 00
200
0

2012

2013

2014

2015

2016

2017

2018

2020

Figure 8. Estimated number of RRT patients in Romania (per million inhabitants)

19

11.176

Preevalent dialysis patients (number)

12, 000
10, 000

8.371

8, 000
6 , 000
3.06 4

4 , 000
2, 000

1.203 1.59 1

1, 16 4
0 39
19 9 5

1, 4 86
105
19 9 6

2.19 5
1, 9 6 0
235
19 9 7

3.56 5

2.715

4 .272

3, 502

4 .9 74

4 , 09 8

5.800

6 .034

8.4 24

9 .09 7

9 .755

10.4 70

6 .9 86

6 .283 6 .715

4 , 700

4 , 9 86

5, 138

5, 4 6 0

5, 587

6 , 9 86

7, 255

8, 06 8

8, 74 8

9 , 551

2, 39 1

2, 6 4 8

3, 04 9

324
19 9 8

4 16

516

770

876

1100

104 8

114 5

1255

139 9

1385

116 9

1029

1007

9 19

19 9 9

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

DP

HD

10, 322

854
2013

Total

Figura 9. Prevalent dialysis patients in Romania (numbers, 1995-2013)

Dialysis patients

However, the rate of increase decreased to 6.7% in 2013,


below the average of the last 5 years (Figure 10).

d e a n u l a n te ri o r

The rate of increase was not constant: the initial fast increase
(1996-2000; +32.7%/year) slowed down (2001-2003 and
2004-2006), and nally the rate increased again to 7.3%/year
in 2007-2013 (Figure 9).

P r o c e n te fa

Since 1996 the total number of patients prevalent on dialysis


constantly increased, exceeding 11,000 in 2013 (Figure 9).

9
8, 0%

8
7

7, 2%

7, 3%
6 , 7%

6 ,4 %

6
5
4

2009

2010

2011

2012

2013

Figure 10. The rate of increase in prevalent dialysis


patients in Romania (2009-2012; in percentage as
compared to the previous year)

20

Prevalence of Chronic kidney disease;


Resources allocated for dialysis, i.e. number of
dialysis facilities and reimbursement by Health
Insurance House;
Eciency of the transplantation program.

Since there are no reasons to believe that CKD


prevalence diers in Romania from Europe, the
prevalence of dialysis patients should be similar.
Therefore, the number of dialysis patients shall
increase gradually in Romania until it reaches the
European average. In 2013 there were 666 dialysis
patients per million inhabitants (pmi) in Romania,
compared to the European average of 883, which
corresponds to a total number of dialysis patients
of 17,660 in Romania (Figure 11). Thus, the number
of Romanian dialysis patients shall continue to grow
by more than 5% each year until it reaches 18,000,
depending on the Health Insurance House funding.
The lower than 7% rate of increase in prevalent
patients observed in 2013 is probably due both to
the progressive coverage of the dialysis need of
the population and to the more active transplant
program. As the number of prevalent patients (an
indicator of the dialysis coverage) increases, the
rate of increase in the number of patients has a
decreasing trend (Figure 12).

883

800
6 00
4 00

353

318

331

2004

2005 2006

4 20

4 9 8

507

582

54 7

59 2

6 6 6

200
0

2007 2008 2009

2010 2011 2012 2013 EDTA


( 2010)

Figure 11. Dialysis patients in Romania (2004-2013) and in Europe (2010)


(per million inhabitants - pmi)
15000

9
8.5

8.0
12500
7.2
10000

7.3
11, 176

9 , 755

7.1

6 .5

84 24
2009

2010

2011

7.1

6 .7

9 , 087
7500

7.5

11, 84 8

10, 4 70

6 .4

12, 537

2012

Number of prevalent patients

Rate of increase ( %)

Number of prevalent patients

The number of dialysis patients depends on the:

Prevalent dialysis patients (pmi)

1000

2013

2014

2015

Rate of increase (%)

Figure 12. Estimated trends in prevalent patients number and in the rate of increase
(percent of the previous year) in Romania 2009-2015

21

15, 000

4 19
10, 000

8, 371

4 21

4 55
9 , 09 7

8, 4 24

524

4 88
9 , 755

10, 4 70

559

11, 176

582

11, 6 31

12, 226

2, 017

2008

2009

2, 4 88

2010

2, 4 9 8

2011

12, 821

701

6 71

13, 4 16

14 , 010

14 , 6 05

76 0

15, 200

800

6 00

4 00

5, 000
2, 24 8

6 4 1

6 11

730

2, 86 4

2, 79 9

2012

2013

Prevalent patients (number)

3, 06 2

2014

3, 39 5

2015

Incident patients

3, 589

2016

3, 6 14

3, 557

2017

2018

4 , 051

3, 886

2019

2020

200

Incident dialysis patients (number)

Prevalent dialysis patients (number)

20, 000

Prevalent patients (pmpi)

Figure 13. Estimated prevalence and incidence of dialysis patients in Romania (pmi - per million inhabitants)

The model in Figure 14 suggests that, if the current trends are maintained:
The estimated rate of increase in prevalent patients number for 2014-2015 is 7%;
In 2014, 11,600 patients will be treated by dialysis, and in 2015, 12,200.
In 2014, 3,100 new patients will be included in dialysis, and in 2015, 3,400.
22

Hemodialysis patients

The number of incident hemodialysis patients


doubled from 2007 to 2013. The prediction for
2014 and 2015 is of 3,400 and 3,600 incident
hemodialysis patients (Figure 14).
If the current trends are maintained:
by the end of 2014 there will be 11,000
patients treated by hemodialysis, and by the
end of 2015, 11.800.
In 2014 and 2015 there will be 3,400 and
respectively 3,600 incident hemodialysis
patients.

16 .00
Prev alent HD p atients ( thousands)

The number of prevalent hemodialysis patients


steadily increased, faster within the last 5 years.
If the current trends are maintained, by the
end of 2014 11,000 patients shall be treated by
hemodialysis, and by the end of 2015, 11.800
(Figure 14).

12.00

8.00

6 .9 9

7.26

8.07

8.75

9 .55

10.32

11.05

11.79

12.54

13.20

14 .01

14 .75

15.4 9

5.59
4 .00
1.9 1
0.00

2.04

2.38

2007 2008 2009

2.6 6

2.9 8

3.4 4

2.6 4

3.38

2010 2011 2012 2013 2014

3.58

3.78

2015 2016

3.9 6

4 .11

4 .26

2017 2018 2019

4 .4 2

2020

Figure 14. Estimated number of incident and prevalent hemodialysis (HD) patients in Romania

23

Peritoneal dialysis patients

14 00
Prevalent PD patients (number)

Peritoneal dialysis has a series of advantages, both


medical (low patient dependence on the dialysis
center, better preservation of renal function than
hemodialysis) and economic (lower therapy cost,
which would allow to treat more patients with the
same budget). Although peritoneal dialysis has few
medical contraindications, the proportion of PD
patients is decreasing in Romania and worldwide. If
the current trend is maintained, peritoneal dialysis
shall practically disappear in Romania by the year
2020 (Figure 15).

16 00

R = 0.9 7

139 9 1385
1255

116 9

1200

1029 1007

1000

9 19

854

800

780
6 52

6 00

56 2

503

4 25

330

4 00

24 3

200

Although the causes of the decrease in peritoneal


dialysis usage are less understood, three factors
seem relevant:
Decient predialysis CKD care, imposing
emergency initiation of RRT, not allowing the
patient to choose in full awareness the most
suitable therapy;
The costs for the initiation of peritoneal dialysis
therapy are not deducted to the hospitals by the
National Health Insurance House;
The price dierence, which is detrimental to
peritoneal dialysis and makes it less attractive
for the private sector than hemodialysis. Thus,
in most of the countries with dominant private
sector, the use of peritoneal dialysis is decreasing,
which was also noticed in Romania (Figure 16)

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Figure 15. Estimation of prevalent peritoneal dialysis (PD) patients number in Romania

100%

9 5%

87%

80%
6 0%
4 0%

30%
16 %

20%
20%
0%

2007

17%

14 %

11%

2008

2009

2010

Patients treated by private providers ( % )

12%

12%

11%

10%
2011

9 %
2012

8%
2013

PD patients ( % )

Figure 16. The proportions of patients treated by peritoneal dialysis (PD)


and of those treated by private dialysis providers in Romania

24

4 , 000

On the other hand, the costs of peritoneal dialysis


were more aected by the recent increase of the VAT
tax, of the currency exchange rate and by the changes
in the medicine price calculation, not mentioning
the more costly newly introduced peritoneal
dialysis solutions than the costs of hemodialysis
(24% vs. 13%). Accordingly, as peritoneal dialysis is
economically less attractive then hemodialysis for
private providers, its usage will be restrained.

3, 500
Incident p atients ( number)

Although CKD evolution is predictable, which


would allow preparing the patients in time for
RRT initiation, including appropriate education,
in Romania there are no programs addressing
predialysis CKD care. That is why renal replacement
therapy is frequently initiated in an unplanned
manner, and the patients have not the possibility to
choose in full awareness their best suited method
of therapy. Accordingly, developing programs of
predialysis CKD care with an educational component
would also allow reversing the descending trend in
peritoneal dialysis usage.

R = 0.89 15R = 0.84 4 3

3, 000

2, 4 88

2, 500
2, 000
1, 500

1, 572

3, 380

3, 26 9
2, 801

3, 6 38

2, 6 4 4

1, 9 88

1, 6 6 9

1, 000
500
0

338
2007

36 7
2008

39 0

2009

183

174
2010
HD

2011

174
2012

155
2013

9 1
2014

34
2015

DP

Figure 17. Trends in dialysis methods usage in Romania


(incident patients; HD hemodialysis; DP peritoneal dialysis)

If the programs for re-establishing the use of PD are successful, by the end
of the years 2014 and 2015 there will be 800-900 patients treated by PD,
and 100-150 patients shall be included in the treatment in the years 2014
and 2015 (Figure 18).

25

Patients treated by other dialysis


methods
Hemodialtration (HDF) and automated peritoneal
dialysis (APD) are conditionally accepted by the NHIH
for reimbursement up to 7-10% of prevalent patients,
due to their higher costs than those of the conventional
therapy. Their use was not widespread, as they are
prescribed to 6.4% and 1.4% of the HD and DP prevalent
patients, respectively (Figure 18).
However, by changing the eligibility criteria for
patients accepted by NHIH, i.e., young patients with
no transplantation perspective for HDF, and raising
the limit for APD to allow young patients having a high
transplantation probability to be treated, would allow a
better allocation of the resources.
Hemodialtration and automated peritoneal
dialysis treatments are prescribed within the
limits accepted by NHIH.
Changing the eligibility criteria for these
treatments would allow a better allocation of
the resources.

100%

DPA 1,0%

DPA 1,4%

9 5%

DPCA
7,8%

DPCA
6,2%

HDF
4,0%

HDF
6,2%

9 0%

DPCA
HDF

85%

80%

DPA

HD
HD
87,2%

HD
86,1%

2012

2013

75%

Figure 18. The proportions of patients treated by various RRT methods in Romania
(prevalent patients on 31.12.2012; N=10,470; prevalent patients on 31.12.2013;
N=11,169; DPA automated peritoneal dialysis; DPCA continuous peritoneal dialysis;
HDF hemodialtration; HD- hemodialysis)

26

Transplant patients

Most of the grafts came from deceased donors


(56%), showing an increase compared to 2012
(Figure 20).

R = 0.7781

10.0%

3, 158

8.0%
6 .0%

1, 9 33

2, 4 21

2, 073

3, 700

3, 59 1

6 .2%

5.5%

7.0%

0.0%

3, 000
2, 000
1, 500

4 .0%
2.0%

4 , 000

2, 500

7.2%

4 .1%

4 , 500
3, 500

3, 017

2, 6 81

3, 9 4 6

1.2%

2007

1.8%

1.8%

1, 000

0.7%
2008

2009

2010

500
2011

2012

Incident RRT patients

2013

2014

2015

Incident RRT patients (number)

However, data are not accurate enough, since


they are based on dialysis centers reports and
include only non-preemptive transplants, as a
functional transplant registry does not exist in
Romania. Moreover, as there are no follow-up data
in transplanted patients, the real contribution of
transplant to the renal replacement therapy can
hardly be assessed.

12.0%
Non-preemptive transplants
(%)

As compared to dialysis, renal transplantation has


medical and economic advantages, but is less used
in Romania. Although the number of grafts has
continuously increased within the last 3 years, only
7% of incident RRT patients were non-preemptively
transplanted in 2013 (Figure 19).

Non-preemptive transplants

Figure 19. Incident patients on day 1 in renal replacement therapy in the period 2007-2015 and the
percentage of non-preemptive transplant patients)

100%

The number of renal transplants increased, the


grafts from deceased donors are predominant,
but transplantation still contributes to a lower
proportion to RRT (7% of the incident patients).
Although 230 and 275 non-preemptive transplants are estimated for 2014 and 2015, at least
400 should be nanced to help transplantation
eectively contribute to RRT in Romania.
In order to obtain accurate data on transplanted
patients, mandatory reporting of the transplant
patients to the Romanian Renal Registry should
be introduced.

16

18.8

75%
Donor of uknow n type
Cadaveric donor

50%

53

56

U nrelated living donor


Related living donor

25%

0%

2.7

28

22.5

2012

2013

Figure 20. Origin of kidney grafts for non-preemptive transplantation in 2013 and 2014

27

NHIH records included 2,723 prevalent transplant


patients, an 11% increase as compared to 2012.
Thus, renal transplantation recorded the highest
increase among renal replacement therapy
methods in Romania, exceeding even hemodialysis
rate (Figure 21).
Renal transplantation had the highest
increase among renal replacement therapy
methods, as judged by the number of
prevalent patients.
It could be estimated that the number of
prevalent transplant patients will exceed
3,000 in 2014.

Prevalent patients 2012/ 2013 ( %)

12%
10%
8%

11%
8%

6 %
4 %
2%
0%
-2%
-4 %
-6 %
-8%

HD

-7%
D P

RTx

Figure 21. Rate of variation (2013/2014; %) in RRT prevalent patients number

28

2011

D ialysis p rev alent p atients ( p mi)

Territorial distribution of RRT


methods
The territorial coverage with renal replacement therapy
is inhomogeneous.
The areas with the highest coverage are around
university centers (B, IS, CJ, TM, BH, SB), while Tg
Mure is a remarkable exception. Other areas with a
good coverage are VN, BR, HD, GJ and MH (due to the
higher prevalence of the Balkan en-demic nephropathy
in this area).

2013

D ialysis p rev alent p atients ( p mi)

The center and North-East of Transilvania (CV, MS, SJ,


BN), the South of Muntenia (GR, CL, TR, IL), the South
of Moldavia (GL) and Oltenia (OT) have the lowest
rates of coverage by dialysis. Compared to 2011, the
coverage improved in HR and IL, but it dropped in the
AR, CS, IL, OT and TR counties (Figure 22, Figure 23).
The inhomogeneous coverage will perpetuate, as the
counties having the highest prevalence also have the
highest number of newly included patients, while the
counties with the lowest number of prevalent patients
reported in 2013 less inci-dent patients that the
national average (Cl, CV, CS, GL, GR, IL, OT) (Figure 23).

Figure 22. Distribution of dialysis patients in Romania at 31.12.2012 (up) and


31.12.2011 (down). The counties having within both years the lowest prevalence
rates in the country have been highlighted. Data are expressed in number
of patients treated per million inhabitants (pmi). The color scale is dened by
the national median and by the quartiles.

29

There are high dierences in dialysis coverage


between the counties of Romania.
Since in counties with university centers there
are up to 3 times more dialysis patients than
the adjoining counties, a possible explanation
of the inhomogeneous distribution would
be the patients preference for university
centers.
Several counties had the lowest prevalence
of the dialysis patients in consecutive years
and the lowest number of newly included
patients in the country (IL, CL, GL, GR, OT, MS,
CV). These counties seem to be the target
of the programs addressing Chronic kidney
disease.

MH
B+IF
IS
SB
BR
V N
CJ
GJ
BH
HD
V S
NT
BT
V L
BV
DJ
AB
BC
Romnia
SV
TL
AG
CT
BZ
TM
HR
MM
SM
PH
DB
AR
SJ
BN
CV
TR
OT
IL
MS
CS
GL
CL
GR

151

14 1
132
108

19 1
19 6

9 6
57
80

4 7

0
0

205
227

137
16 6
16 5
102
88
150
210
103

14 0
9 8
116
80
9 2
113
9 4
121
176
129
133
81
134
76
6 6
38
4 1
6 3
20
100

200

750
750
738
375
720
713
6 73
6 73
6 4 7
6 4 7
6 19
6 04
59 1
582
578
574
572
570
558
555
550
54 9
527
513
505
4 9 0
4 86
4 81
4 6 8
4 6 5
4 6 1
4 4 1
4 4 1
4 4 0
4 33
4 29
4 03
39 0
372
36 2
332

330

274
26 3
300

4 00

500

6 00

700

Prevalent patients
Incident patients

800

Figure 23. Dialysis prevalent and incident patients (per 1 million inhabitants) in
Romanian counties (in descending order)

30

2013
PD incident patients (pmi)

Theoretically, the renal replacement therapy


methods should be complementary used to match
the patients needs. Based on incident patients
allocation to the RRT methods, in Romania there
are four pattern of prescription: HD combined with
PD and RT (the most advised), HD combined only
with PD (without RT), HD com-bined only with RT
(without PD) and exclusive HD (the least advised).
Even though in most of the counties all three
methods are prescribed, in some of them HD is used
either only in association with PD (South Moldavia,
East Muntenia), only with RT (Central Transilvania),
and in others HD is prescribed exclusively
(Table VIII, Figure 24).

2013
RTx incident patients (pmi)

Table VIII. Patterns of RRT prescription in the counties


of Romania (2013)

HD+DP+TR
HD+DP
HD+TR
HD

AG, B+IF, BH, BV, CJ, CS, CT, DJ, GL,


HD, IS, SB, SM, TM
BR, BZ, PH, OT, TR, VN
AB, AR, BN, HR, MS, NT, SJ, TL, VS
CL, GR, IL, MM, SV

The use of renal replacement therapy


methods in Romania shows signicant area
variations, reecting the lack of an unitary
practice and can inuence both the evolution
of the patients, and the costs of renal
replacement therapy.
Figure 24. The distribution of incident patients in peritoneal dialysis (PD - up) and in nonpreemptive renal transplantation (RTx - down). The renal transplantation centers and the areas
prescribing RTx and HD (blue), PD and HD (green) and exclusively HD (red) are highlighted.

31

The RRT in children


In 2013, from the eight pediatric functioning
centers, ve are only discontinuously functioning.
The total number of children treated by dialysis on
31.12.2013 decreased slightly, reaching to 121.

Table IX. Dialysis therapy in children in Romania (2007-2013)


2007

2008

2009

2010

2011

2012

2013

The number of children incident in dialysis


continued to have an increasing trend, reaching up
to 30 in 2013.

Centers (number)*
Number

103

110

119

115

117

123

121

The ratio of patients treated by peritoneal dialysis


continued to decrease down to the maximum level
of 30% reached in 2008, reaching to 6.7% in 2013
(Table IX).

Sex (B%)

53,4

51,8

52,1

53,0

52,6

52,1

52,3

Number

35

30

29

28

28

28

30

Sex (B%)

51,3

47,8

54,0

52,4

52,6

51,9

50,0

- HD (%)

85,4

63,4

68,5

70,4

81,0

84,6

93,3

- DP (%)

14,6

36,6

28,1

29,6

19,0

14,1

6,7

Hemodialysis is the most frequently used


RRT method in Romanian children, even
though renal replacement therapy in children
should be based on peritoneal dialysis and
transplantation.
There are no available data about transplantation in children.

Prevalent patients on 31.12

Incident patients day 1

Dialysis method at RRT initiation

*Five pediatric centers function intermittently

32

9 , 000

Survival of RRT patients

4 , 000

1.58
3, 886

1.36

1.5

1.30

1.07

1.27
1.00

3, 000
2, 000

Fresenius

0.5

9 34

9 56

9 4 5

74 8

6 9 2

Public

IHS

D iav erum

Av itum

Other

Romania

Figure 25. Standardized mortality ratio (SMR) in hemodialysis patients by provider (2012)

10, 000

886 5

9 , 000
Prevalent HD patients (number)

In 2012 and 2013, the mortality rate of


hemodialysis patients in Romania increased
by 27% and 23%. Among the dialysis
networks, only the Fresenius recorded in
both years a similar mortality rate to the
reference, while IHS and Avitum SMRs
decreased in 2013 to the reference, after
being higher in 2012. Public dialysis centers
have a double mortality rate compared to
the reference level (Figure 25, Figure 26).

5, 000

1, 000

This type of analysis allows the comparison


between the mortality observed in a
population or in cohorts specically dened,
and the national mortality rate assessed in a
reference cohort (see Appendix 1).
A SMR strictly above or below 1 describes
in percentage how higher or respectively
lower is the mortality rate versus the
national reference rate. SMRs not strictly
above or below 1 indicate mortality rates
similar cu the national reference rate.

6 , 000

SMR

Standardized mortality ratio (SMR) is


the ratio between the observed and the
expected number of deaths. SMRs are used
to compare the survival of the patients
treated in a center (county or network) to
the national mortality rate.

2.00

7, 000

2.5

8, 000

2.25

7, 000

6 , 000
5, 000
4 , 000
3, 000

1.5

4 132

1.09

2, 000
1, 000
0

Fresenius

1.09

1.26

1.19

1.23

1.05

877

1034

104 3

889

6 9 2

Public

IHS

D iav erum

Av itum

Other

SMR

Standardized mortality ratio

8, 000
Prevalent HD patients (number)

Survival is a synthetic indicator of the quality


of dialysis therapy.

2.5

8, 16 1

1
0.5

Romania

Figure 26. Standardized mortality ratio (SMR) in hemodialysis patients by provider (2013)

33

Unfortunately, the standardized mortality ratio cannot be used to classify


dialysis centers (Appendix 9).

The HD patients mortality increased by over 20% in the years 2012, 2013,
in Romania as compared to the reference cohort. Since SMR implies
adjustment, the increase in age or in the diabetes mellitus proportion of
incident patients does not fully account for the rise of the mortality rate.
As other comorbidities or other factors can be involved, further analyses
are needed for clarication of the observed increase in mortality.
Public centers had twice higher SMR than the reference rate, probably
because they initiate the treatment (period with the highest death risk)
and treat the cases with the highest burden of comorbidities.

34

Survival rates

Survival

The mean survival of the RRT patients starting the treatment


in 2008-2011 was 3.9 0.02 years (adjusted survival rates 1
and 4 years, 86% and 76%) (see Appendix 2 for the calculation
method)5.
Replacement therapy method (HD and PD more than RTx),
older age and diabetes mellitus are factors independently
associated with the decrease of survival rates (Table X). Young
patients with a kidney graft, without diabetes mellitus and with
glomerulopathies had the best chances of survival (Table XI,
Figure 27).
TableX. Adjusted* survival rates (%) by RRT method
1
year

2
years

3
years

4
years

HD

84,8%

79,7%

75,4%

73,6%

PD

84,9%

79,7

75,5%

73,6%

RTx

97,1%

96,0

95,0%

94,7%

RRT

86,1%

81,2%

77,4%

72,5%

*by gender, age, primary kidney disease

Time (months)
Figure 27. Cumulative survival rated of patients starting renal
transplantation (TR), hemodialysis (HD) or peritoneal dialysis (DD)
in 2008-2011 in Romania
Table XI. Determinants of RRT patients survival in Romania
Determinants
RRT vs RTx
HD (vs. RTx)
PD (vs. RTx)

RTx patients had 5 times more chances of sur-vival


than those treated by HD or PD.
HD and PD had comparable results.
Diabetes mellitus and increasing age reduced the
survival rates by 25% and 3%, respectively.

HR

5,61
5,63

<0,001
<0,001
<0,001

Age

1,03

<0,001

Gender: Female vs. Male

0,94

0,5

Primary kidney disease (vs. Renal vascular diseases)

Glomerular nephropathies

Tubule-interstitial nephritis

Hereditary nephropathies

Diabetic nephropathy

Unknown/ Others

0,75
0,94
0,62
1,25
1,13

<0,001
<0,01
0,5
<0,001
0,01
0,1

35

International comparisons
The most recent reports published by USRDS
(2011) and EDTA ERA Registry (2012) were used for
comparison7,8.

Incident patients
In 2011, Romania continued to be below the
European average of the incident patients (127
vs. 130 pmi), but had one of the highest rates of
increase (66% vs. 6%) (Figure 28, see also Figure 29,
Figure 30).

The proportion of diabetic patients incident in


dialysis in Romania is one of the lowest in Europe. A
possible explanation could be the lack of resources
limiting the access to treatment of the patients
with diabetes mellitus and other comorbidities.
Considering that the rate of increase in dialysis
incident patients in Romania is one of the highest
in Europe, and the average of prevalent patients
approaches the European average, it would be
expected that the ratio of the incident diabetic
patients would also increase. However, this is not
the case: the rate of increase of in the proportion
of incident diabetic patients in Romania is one
of the lowest in Europe). Accordingly, either the
prevalence of diabetes is overestimated in Romania,
or the diabetic predialysis CKD patients mortality is
signicantly higher (Figure 32, Figure 33).

Figure 28. Incident RRT patients in the Europe in 2011 (EDTA-ERA Registry 2011)

70%
6 0%

53%

50%
Percent

Although increasing, the average age of incident


patients in Romania is lower than in Europe or USA
(Figure 29).

4 0%

39 %

59 %

59 %
4 9 %

4 9 %

50%

4 2%

32%

30%
20%
10%
0%

Romania

Europa
2006

2010

SU A

2011

Figure 29. The proportion of RRT incident patients with ages above 65 years of age in
Romania (RRR, USA (USRDS) and Europe (EDTA-ERA Registry)

36

SU A

36 9

Japonia

6 6

288

Turcia

50

252

Portugalia

4 3

239

Republic Ceh

19 8

Belgia, olandez

19 5

Belgia, francez

19 2

Grecia

19 0

Frana

14 9

Croaia

14 2

Austria

139

Marea Britanie

136

Bosnia

31
19
7

133

Europa ( ERA-EDTA)

130

Romnia

124

Danemarca

121

Spania

121

Suedia

121

Olanda

118

Romnia
I slanda
Rusia
Turcia
Marea Britanie
Republic Ceh

Europa ( ERA-EDTA)

Olanda

Japonia

Norvegia

Frana

Belgia, francez

Danemarca

Belgia, olandez

SU A

Croia

Bosnia

-4

Grecia

Norvegia

104

-5

Spania

I slanda

104

-6

Finlanda

9 9

-7

Suedia

Scoia
Finlanda
Rusia

81
4 0

Figure 30. Incident RRT patients in 2011 (pmi) (international comparison)

-13
-15

Austria
Scoia

Figure 31. Variation 2011/2006 (%) in incident RRT patients number (pmi)
(international comparison)

37

Republica Ceh

24 .8%
Finlanda
24 .2%
Portugalia21.2%
14 .3%
Austria
13.8%
Croaia
7.6 %
7.0%
Grecia
4 .1%
Marea Britanie
2.3%
Spania
-0.5%
-1.8%
Boznia
-2.4 %
Suedia
-6 .6 %
-7.0%
Scoia
-8.5%
Danemarca
-10.1%
Frana
-12.1%
-13.4
% ( ERA-EDTA)
Europa

37.9 %

I slanda
35.0
Rusia
34 .6
Marea Britanie
Bosnia
31.5
Croaia
30.1
Danemarca
30.0
Scoia
Romnia
29 .2
Spania
25.6
Frana
24 .6
Europa ( EDTA-ERA)
Finlanda
24 .3
Olanda
23.8
Belgia ( olandez)
Suedia
23.3
Grecia
23.0
Belgia ( francez)
21.6
Austria
Norvegia
21.5

Belgia ( olandez)

21.0

Belgia ( francez)

20.7

Norvegia
Rusia
I slanda

17.1
15.8
15.2

37.9 %
24 .8%

Rusia

24 .2%

Marea Britanie

21.2%

-0.5%

Bosnia

14 .3%

Croaia

13.8%

Danemarca

7.6 %

Scoia

7.0%

Romnia

4 .1%

2.3%

I slanda

Spania
Frana
Europa ( EDTA-ERA)

-1.8%

Finlanda

-2.4 %

Olanda

-6 .6 %

Belgia ( olandez)

-7.0%

Suedia

-8.5%
-10.1%

Grecia
Belgia ( francez)

Romania

14 .2

-12.1%

Austria

Olanda

14 .1

-13.4 %

Norvegia

Figure 32. The proportion of diabetic patients incident in RRT in 2011


(international comparison).

Figure 33. Variation 2011/2006 (%) of the proportion of diabetic patients


incident in RRT (international comparison)

38

80%

74 .3%

70%
6 0%
50%

Prevalent patients
Even though it increased rapidly after 2006, the
number of prevalent RRT patients remained in 2013
one of the lowest in Europe (732 in 2013 compared
to the European average of 891 pmi in 2011). Yet
the increase rate in Romania continues to be one
of the highest among the European countries and
it is 3 times higher than the European average (see
Figure 34, Figure 35).

RRT method
In prevalent patients from Europe, hemodialysis and
renal transplantation were used in 2010 in almost
similar proportions (51% and 42%) followed by
peritoneal dialysis (8%). In Romania, hemodialysis
was the most frequently used (74%), followed
by renal transplantation (20%) and by peritoneal
dialysis (6%) (Figure 35).
In Europe, in incident patients, hemodialysis was
the most frequently used method (79%), followed
by peritoneal dialysis (15%), while the pre-emptive
renal transplantation was performed in 6%. In
Romania, HD is also highly dominant, followed by
PD and in only 1% of cases by RTx (Figure 36).
Although the increase in patients with a functional
kidney graft was seven times higher than the European
rate, in Romania the proportion of RTx patients
is almost half of the European mean (Figure 40
(see Figure 39).

Europe ( 2011)

50.8%

4 1.6 %

4 0%

Romania ( 2013)

30%
19 .6 %

20%
7.6 %

10%
0%

HD

6 .1%
DP

TR

Figure 34. The proportions (%) of prevalent patients treated by hemodialysis (HD),
peritoneal dialysis (DP) and renal transplantation (TR) in Europe and Romania
100%

9 3.3%
79 .0%

75%

Europe ( EDTA)

50%

Romania
25%

15.4 %
5.7%

0%

HD

DP

5.6 %

1.0%
TR

Figure 35. The proportions (%) of incident patients treated by hemodialysis (HD),
peritoneal dialysis (DP) and renal transplantation (TR) in Europe and Romania

39

Japonia

2, 309

SU A

1, 9 24

Belgia, francez

1, 271

Republica Ceh
Romnia

1, 184

Turcia

Grecia

1, 103

I slanda

Frana

1, 09 1

Bosnia

1, 075

Austria

1, 001

Croaia

9 80

Republica Ceh
Olanda
Suedia

104 .8%

Rusia

Belgium, olandez

Spania

110.9 %

50.9 %
4 7.4 %

37.3%
27.7%

Olanda

24 .5%

Marea Britanie

20.5%

Belgia, francez

18.6 %

9 74

Japonia

18.1%

9 6 1

Norvegia

16 .1%

SU A

15.7%

9 30

Norvegia

874

Belgium, olandez

14 .6 %

Marea Britanie

871

Croaia

14 .5%

Turcia

86 8

Frana

13.3%

Danemarca

851

Grecia

11.9 %

Scoia

84 2

Spania

11.8%

Finlanda

10.4 %

Austria

10.2%

Suedia

9 .3%

Danemarca

8.8%

Scoia

7.4 %

Finlanda

803

Bosnia

705

I slanda

6 6 5

Romnia
Rusia

6 24
19 6

Figure 36. Patients prevalent on RRT at 31st of December 2011 (pmi) (international
comparison) NB. In 2013, in Romania there were 732 patients treated pmi

Figure 37. Variation 2011/2006 (%) in number prevalent patients undergoing


RRT (international comparison)

40

As compared to the trends in the European


countries in 2011/2006, Romania has recorded a
higher increase in the percentage of hemodialysis
patients, a higher decrease in the percentage
of peritoneal dialysis patients and a signicant
increase of the prevalent transplanted patients
(Figure 38).

Romania has one of the lowest prevalence


rates of the patients treated by renal
replacement therapy methods in Europe, yet
one of the fastest increase rates.
In Romania, hemodialysis is the most
frequently used RRT method, while in Europe
hemodialysis and renal transplantation and
are used at similar rates.
Patients with functional kidney graft have a
lower prevalence in Romania, but the rate
of increase rate was one of the highest in
Europe.

Norvegia
Portugalia
Olanda
Spania
Suedia
Austria
Frana
Finlanda
Marea Britanie
Danemarca
Cehia
Croia
Grecia
Romania ( 2012)
Serbia
Turcia
Bosnia Heregovina
Rusia

4 6
4 2
0

100

336

221

126
102
9 5

200

39 9
39 0

300

4 00

4 34

538
520
500
4 83
4 74

500

6 29
6 10
577

6 00

700

Patients with a functional kidney graft (per million inhabitants)

Figure 38. Variation 2011/2006 (%) in prevalent RRT patients number in Europe and in Romania
(HD hemodialysis; DP peritoneal dialysis; TR renal transplantation)

TR

23.0%

-37.0%
DP

-20.6 %
8.8%

HD
-50.0%

138.0%

3.5%
0.0%

50.0%
Romania

100.0%

150.0%

Europe

Figure 39. Trends of the use of renal replacement therapy methods in Europe
and in Romania (variance 2011/2006, in percentage)

41

Survival on RRT
A cohort of dialysis patients who started the therapy in 2006-2010 in Romania (N=10.588) was comparatively analyzed with corresponding data reported by
EDTA-ERA Registry. The unadjusted survival rate of the patients treated in Romania is lower within the rst three months, but signicantly better after one
and two years, which emphasizes once again the deciencies in the care before starting the dialysis (Table XII, Figure 40).
Table XII. Unadjusted survival rate at 90 days, 1 year and 2 years for the cohort 2006-2010, incident dialysis patients in Europe and Romania
Parameter
Age groups (years)
0-19
20-44
45-64
65-74
75+

90 days

1 year

2 years

EDTA-ERA

RRR

EDTA-ERA

RRR

EDTA-ERA

RRR

98.8 (97.7-99.4)
99.0 (99.8-99.1)
96.7 (96.5-96.9)
93.4 (93.1-93.7)
89.3 (89.0-89.6)

94.1 (90.4-97.8)
98.1 (97.5-98.6)
93.2 (92.4-93.9)
89.6 (88.4-90.7)
82.5 (80.3-84.6)

96.0 (94.1-97.3)
96.2 (95.8-96.5)
89.3 (88.9-89.6)
80.6 (80.2-81.0)
71.2 (70.8-71.5)

92.7 (88.6-96.8)
94.9 (93.9-95.8)
86.9 (85.9-87.8)
81.8 (80.2-83.3)
72.6 (70.0-75.1)

93.8 (91.4-95.6)
91.9 (91.4-92.4)
81.0 (80.6-81.4)
68.0 (67.6-68.3)
54.8 (54.5-55.1)

91.2 (86.7-95.7)
92.2 (90.8-93.5)
80.5 (79.3-81.6)
71.7 (69.0-73.0)
63.7 (60.9-66.4)

Sex
Male
94.1 (93.3-94.2) 91.3 (90.5-92.0) 82.4 (82.1-82.6)
84.6 (83.6-85.5)
70.4 (70.1-70.6)
77.8 (76.8-78.7)
Female
93.5 (93.3-93.7) 92.6 (91.8-93.3) 81.7 (81.4-82.1)
86.1 (85.1-87.0)
70.2 (69.8-70.5)
79.2 (78.0-80.3)
Primary kidney disease
71.4 (69.0-73.7)
69.1 (68.6-69.5)
82.3 (80.3-84.2)
Diabetic nephropathy
95.0 (94.7-95.2) 91.4 (89.8-92.9) 82.9 (82.5-83.3)
75.0 (71.8-78.1)
67.5 (67.0-68.0)
83.0 (80.4-85.5)
HBP/Renal vascular disease
94.2 (93.9-94.5) 92.1 (90.1-94.0) 81.3 (80.8-81.8)
84.1 (83.5-84.7)
86.1 (84.3-87.8)
91.1 (89.7-92.4)
97.3 (97.0-97.6) 95.8 (94.8-96.7) 91.2 (90.7-91.7)
Glomerulonephritis
69.8 (69.5-70.1)
78.4 (77.4-79.3)
84.7 (83.9-85.4)
92.9 (92.7-93.1) 91.0 (90.2-91.7) 80.8 (80.5-81.1)
Other causes/ not specied
Total
93.9 (93.7-94.0) 91.9 (91.3-92.4) 82.1 (82.0-82.3)
85.3 (84.7-85.8)
70.3 (70.1-70.5)
78.4 (77.6-79.1)
Red survival rate lower in EDTA-ERA Registry (EDTA-ERA); Blue survival rate higher in Romanian Renal Registry (RRR)

100%

9 3.9 %

9 1.9 %
82.1%

80%

Romanian dialysis patients chances


of survival are lower in the rst 90
days, but better after 1 and 2 years,
as compared to data reported by the
EDTA-ERA Registry.

EDTA-ERA
Ro

85.3%
70.3%

78.4 %

6 0%
4 0%

20%
0%

9 0 days

1 year

2 years

Figure 40. Unadjusted


survival rates of incident
dialysis patients in the
period 2006-2010 in
Europe (EDTA-ERA) and in
Romania (all dierences
are signicant)

42

Table XIII. Dialysis centers and prevalent patients by provider in Romania (2012/2011)

Dialysis providers

Prevalent dialysis patients on 31.12

Centers

The number of the dialysis centers has not changed.


The public sector owns most of the centers (42%).
Public centers treated 11% dialysis patients. The
most important private provider of dialysis services
was Fresenius Nephrocare, followed by International
Helathcare Systems, Diaverum, Avitum (45%, 14%,
11% and 9%) (Table XIII, Figure 41).

HD

PD

Total

2012

2013

2012

2013

2012 2013 2012

Public

57

57

1125

1137

136

Avitum

827

998

31

44

Diaverum

10

10

868

1178

52

70

Fresenius Nephrocare

35

35

4543

4714

International Healthcare systems

13

13

1108

1192

Other

14

14

1080

1103

109 1261

2013 Variation*
1246

-1.2%

859

1042

21.3%

920

1248

35.7%

336

281 4879

4995

2.4%

325

323 1433

1515

5.7%

38

27 1118

1130

1.1%

*2013 vs. 2012, in percentage


Others
10%
IHS
14%

Public
11%

4 0%
Av itum
9%
D iav erum
11%

FNC
45%

Figure 41. The ratio of the dialysis service providers


on 31.12.2013 (percentage from the total number
of prevalent patients)

All private providers of dialysis have recorded increases


in the number of treated patients. Diaverum and
Avitum had the highest rate of in-crease (Figure 42).

35.7%

35%
30%
25%

21.3%

20%
15%
10%

5.7%

5%
0%
-5%

2.4 %

1.1%

-1.2%
Public

Avitum

Diaverum

FNC

IHS

Alii

Figure 42. Variation in prevalent patients number 2013/2013 (%) by dialysis service provider

43

The percentage of patients treated in the public centers


continued to decrease and reached the lowest level in
2007 (11%) (Figure 42, Figure 43). Since public centers
in hospitals function as a support for the ambulatory
centers, public dialysis stations should be maintained,
at least in the county hospitals. On the other hand,
policies regarding the privatization/re-privatization of
the public stations should be discouraged, in order to
prevent unfair competition.
There were dierences in the use of the PD by dialysis
providers. In general, PD is preferred only by some of
the private providers (International Healthcare Systems,
Fresenius) and by the public sector. In 2013, most of the
providers recorded a decrease in prevalent PD patients.
The increases recorded by Avitum and Diaverum were
not enough to stop the decline in PD usage in Romania
(Figure 44, Figure 45).
The continuous decrease in PD usage noticed in the
public sector (-20%) is alarming, as it regards the area
where the renal replacement therapy is chosen and
initiated. One of the causes is that the costs for the
initiation of peritoneal dialysis are not reimbursed by
the NHIH. On the other hand, the policies to promote
peritoneal dialysis should be focused not only on
hospitals that initiate renal replacement therapy, but
also on programs for predialysis Chronic kidney disease
care.

5
9 5

13

87

30
2007

2008

88

12

12

2011

2012

2013

84

70

16

2009

2010
Public

9 2

88

Private

Figure 43. The proportion of dialysis patients treated in the public sector (%)

Other
8%

Others
8%

Public
18%
Avitum
5%

Public
18%IHS
32%

IHS
32%

Avitum
5%

Diaverum
6 %

FNC
Diaverum
31%
6 %

FNC
31%

Figure 44. The proportion of PD patients by dialysis providers


(percentage of the total num-ber of dialysis patients)

44

50%

4 1.9 %

4 0%

34 .6 %

30%

Private providers treated 88% of the dialysis


patients.
The public sector treated about 12% of the
dialysis patients. Since public, hospital based
sector functions as a support for the private
ambulatory centers; a further decrease in the
proportion of patients treated in the public
centers is risky.

20%
10%
0%

-0.6 %

-10%
-20%
-30%
-4 0%

-16 .4 %

-19 .9 %

-28.9 %
Public

Avitum

Diaverum

FNC

I HS

Others

-26 .0%
Romania

Figure 45. The trends in peritoneal dialysis usage by dialysis providers in Romania
(PD prevalent patients 2012/2006 in percentage)

45

150

Organization and inancing


Privatization and the public sector
After the initiation of the privatization (2004), the
dialysis network reorganized. The number of the
dialysis centers has doubled, 95 new centers were
founded, mostly as ambulatory departments,
and the public centers existing in hospitals were
transformed into dialysis stations with a low
number of HD units (Figure 46). The private
investment in the new centers amounted around
48.000.000 Euro.
Due to the increase in dialysis treatment capacity,
more patients, which otherwise would have
died, could be treated. The number of dialysis
patients doubled, but the costs per treated patient
decreased since 2004 until 2013 by 19.4% (Figure
47). Accordingly, privatization allowed for increasing
the economic eciency of the dialysis program.
Privatization allowed to treat more patients
by an increase in the economic eciency of
the dialysis program.
Most of the dialysis centers originally located
in hospitals were converted into public dialysis
stations with 4-8 machines. These stations initiate
RRT and ensure the therapy for dialysis patients
requiring hospital admission. Unfortunately, the
process lead to the disappearance of the dialysis
stations in some counties (CL, CV, GR, MH).

120
9 0
134

106
6 0
30

71

70

1
0
2004

2005

137

138

85
69
0
2006

74
5
2007

29

22

11

12
2008

2009

New centers

2010

2011

2012

2013

Total

Figure 46. Dialysis centers in Romania (2004-2012)

20, 000
16,611

16,021

16,449

17,263

15,841
13,861

15, 000

10, 000

6 , 034

6 , 283

6 , 715

6 , 9 86

3, 6 4 4

3, 888

4 , 028

2004

2005

2006

2007

Patients

9 , 09 7

14,013

9 , 755

8, 371

8, 4 24

4 , 880

4 , 9 51

5, 389

5, 79 6

2008

2009

2010

2011

5, 000

3, 508

14,071

Program buget (thousands RON)

14,604

10, 4 70

Costs
-19%
13,910

11, 176
Patients
+100%

6 , 819

6 , 871

2012

2013

Costs per treated patient (EURO)

Figure 47. The number of patients beneting from the dialysis program, the program budget
(hundreds of thousands of RON) and the costs per patient
(Euro, at the reference NBR currency exchange rate for that year)

46

17, 000
TR, 20%
TR, 42%
8%
74%
51%

Europe ( EDTA)

The ratio between RRT methods


Compared to Europe, in Romania the HD is
predominant (74% vs. 51%), while RTx is used
to a lower rate (20 vs. 41%). Since the costs of
therapy diers - HD is the most expensive, and
RTx is the least - the current combination of
the methods leads to higher average costs per
patient under-going renal replacement therapy
(Figure 48).

Sp endings p e year ( million RON)

Establish rules for the deduction of dialysis


sessions performed in hospital at the initiation
of therapy and for admitted dialysis patients;

Allocate around 5-10% of the program funds for


these sessions.

12, 500

Romania

HD

D P

11, 750

TR

Figure 48. RRT methods in Romania (2012) and in Europe (EDTA-ERA).


Estimated costs of the replacement therapy for one patient/year
(HD hemodialysis, DP peritoneal dialysis; TR renal transplantation)

Since the public sector in hospitals is critical for


the dialysis program, it is necessary to:

Introduce the health card for the patients in


the program, which would facilitate treat-ment
records.

7%

C heltuieli/ an ( Euro)

The public sector in hospitals is critical for running


the dialysis program, since private centers
function as ambulatory centers and dialysis
patients frequently suer from comorbidities
requiring hospital admission. However, the
nancing of this segment is decient: even
though hospitals can contract dialysis services,
not all County HIH accept to deduct the costs for
the initiation of the treatment, and the therapy
sessions performed for hospitalized dialysis
patients are not fully reimbursed.

After 5 years, savings amount 10% per year,


allowing new patients to be treated without
an increase in the budget for the dialysis program

Figure 49. Modeling the economic impact of the use of PD in 20% of the incident patients
(Model DP) compared to the current situation (over 80% hemodialysis Model HD) and the increase
of renal transplantations to 30% (Mod-el TR). Five years after the introduction of the PD model, the
estimated savings compared to the current situation would allow including all incident patients without
an increase in the budget.

47

Treatment quality
Moreover, from both a medical and an economical perspective, it would be ideal to
combine PD with RTx, and to initiate HD only in those patients who have no indications
for or refuse PD or RTx, and in those in which these methods have failed.
A model of the economic impact of the increase to 20% in the ratio of incident
peritoneal dialysis patients and to 400 kidney grafts per year shows that after 5 years
the obtained savings would allow newly-included patients to be treated without
increasing the dialysis program budget (Figure 49).
To improve patients allocation to RRT methods, the following are needed:
Programs addressing pre-dialysis CKD patients care;
Financing at least 400 grafts per year (eventually, unlimited number of grafts);
Conditioning the reimbursement of medicine costs in the post-renal transplantation
program by reporting to the Romanian Renal Registry, similar to the dialysis program.
Increasing taris for peritoneal dialysis.

There is no system to assess the therapy


performances, although such a system was one
of the prerequisites for the initiation of the
privatization, and most of the private providers
have implemented quality management systems.
Moreover, a dierentiated payment of services
based on the quality assessment can in perspective
be introduced .
Collecting data on medical performance by
Romanian Renal Registry would allow obtaining
information on the quality assessment and
requires:
to establish compulsory reporting of quality of
therapy parameters by the providers;
to properly reorganize and nance the Romanian
Renal Registry.
48

Table XIV. Weighted inuences on the expenses of the Pro-gram for dialysis renal replacement
a)

Haemodialysis

Nature of cost

Prices of the dialysis services


The dialysis therapy is contracted as a package of
services per a hemodialysis session, respectively per
1 year of therapy for peritoneal dialysis. The package
includes the necessary consumables (dialysis
solutions, bloodlines, stula needles dialyzer, etc.),
medicines (heparin, epoetins, iron, phosphate
chelating agents, vitamin D analogues, cinacalcet),
lab tests, patient transportation, food, dietary and
psychological counseling. It is the most complete
package in the EU and despite that, the price is the
lowest.
Within the last 4 years, a series of inuences
signicantly increased the costs of dialysis: the
increase of the VAT by 4%, the increase of the price
of medicines and introduction of new medicines
(cinacalcet, paricalcitol), 10% for hemodialysis
and 15% for peritoneal dialysis (new solutions for
peritoneal dialysis) and the increase of the Leu/
EURO exchange rate (11%).
The details on the expenses of private providers
cannot be obtained, due to their condential
nature. That is why the impact analysis can only be
performed by a weighted calculation. The weighted
calculation of the impact indicates increases of the
expenses by 13% for hemodialysis and 24% for
peritoneal dialysis. The impact on peritoneal dialysis
is higher due to the newly introduced solutions,
which are more expensive (Table XIV).

Weight within
the expenses (%)

Increase (%)

Weighted increase (%)

HD materials

26.2%

18.35

4.8%

Medicines

20.6%

23.8%

4.9%

Other materials

2.1%

5.0%

0.1%

Laboratory tests

2.0%

0.0%

0.0%

Other medical costs

2.1%

0.0%

0.0%

Other costs

10.8%

5.0%

0.5%

Transportation

10.4%

5.0%

0.5%

Wage costs

25.7%

9.0%

2.3%

100.0%

13.2%

Weight within
the expenses (%)

Increase (%)

Weighted increase (%)

3.4

18.1%

0.6%

Dialysis solutions

62.8

29.4%

18.5%

Medicines

13.4

23.8%

3.2%

Laboratory tests

1.9

0.0%

0.0%

Other medical issues

0.8

0.0%

0.0%

Other costs

2.1

5.0%

0.1%

Solutions transportation

7.4

5.0%

0.4%

0.7%

0.7%

8.1

9.0%

0.7%

100.0

24.2%

Total
b)

Peritoneal dialysis

Nature of cost
PD materials

Patient transportation
Wage costs
Total

The increase of Leu/EURO exchange rate, the increase of VAT, of cost of medicines (including the
introduction of new preparations) and of the wages increased the costs of dialysis therapy. Since
the increase of expenses directly reects on the quality of therapy, it is necessary to increase
prices by 10-13% for HD and by 15-20% for PD.

49

Conclusions
1. Chronic kidney disease has a higher prevalence in Romania that in the
USA: 13.1% vs. 11.5%; the estimated number of adult persons with CKD
in Romania is about 1,900,000.
2. Since the number of CKD patients with medium-high risk is 565,000, a
nephrologist should care approximately 1,900 patients.
3. CKD patients suer more often from diabetes mellitus, HBP, strokes and
heart failure, and their death risk is twice higher. Consequently, CKD care
should be multidisciplinary (diabetology, cardiology and nephrology).
4. The medical assistance is mainly provided in hospital (over a quarter of
the patients are admitted into hospital), regardless of the state of the
kidney, and the CKD patients have almost twice as many visits in the
ambulatory clinic. Thus, it is necessary to organize multidisciplinary CKD
medical care programs that must promote ambulatory care.
5. The framework contract for 2014 included stipulations in favor of the
multidisciplinary care of CKD patients in the ambulatory clinic, but the
Application norms are relatively less precise and cannot be implemented,
since the 10th version of the International Classication of Diseases
used in Romania is not updated to include Chronic kidney disease (N18).
Temporarily, until it is brought up-to-date, we suggest accepting the N18
code (in the current classication - Chronic kidney failure) for the Chronic
kidney disease in hospital admittance cases and the code 685 in the
ambulatory patients.
6. The number of the RRT patients in Romania (732 pmi) is below the
European average of the year 2012 (947 pmi), but it has a rate of increase
above the European mean.
7. The annual rate of increase in RRT patients number is 7-8% and shall only
decrease in 2016-2017, when most of the existing patients shall be able
to receive treatment, and the death rates would equal the rate of the
therapy inclusion. That is why:

a. The rate of increase in HD patients number estimated for 2014-2015 is


6-7%.
b. In 2014, 11,600 patients shall be treated by dialysis, and in 2015,
12,200.
c. In 2014 there will be 3,100 newly included patients, and in 2015,
3,400.
8. The use of peritoneal dialysis is decreasing and should the current trends
maintain, it will disappear by 2017. In order to change this decreasing
trend, the following could be useful:
a. Programs addressing the CKD patients before dialysis initiation;
b. Programs addressing the physicians in hospitals and in the specialty
ambulatory departments;
c. Adjusting the prices for peritoneal dialysis.
9. Renal transplantation:
a. The number of grafts increased and the grafts from deceased donors
were predominant in the incident transplant patients, but only 8% of
incident patients undergone non-preemptive transplantation;
b. At least 300-400 grafts would be necessary each year in order to
allow transplantation to contribute eectively to RRT in Romania.
On principle, the number of grafts for which the costs are deducted
should not be limited, as wasting the available grafts from nancial
reasons is meaningless;
c. The post-transplantation program shall include 2989 and respectively
3255 patients for the years 2014 and 2015.
d. In order to have a proper evidence of RTx patients, compulsory
reporting of the transplant patients to the Romanian Renal Registry

50

should be introduced, by conditioning the deduction of 100%


deducted prescription for the patients in the post-transplantation
program by reporting.
10. Hemodialtration and automated peritoneal dialysis treatments are less
frequently used. In order to use them more eciently it is indicated to
change the currently accepted by NHIH prescription criteria.
11. The renal replacement therapy is inhomogeneously provided at the
territorial level:
a. The center of Transilvania, South of Muntenia and Moldavia
(especially in the counties IL, CL, GR, OT, MS, CV) continue to have
a lower coverage with dialysis facilities and low perspectives for
improvement.
b. The indications of the use of renal replacement therapy methods
signicantly vary from one area to another: in the center of
Transilvania, hemodialysis and renal transplantation are especially
used and peritoneal dialysis does not exist, while in the South of
Moldavia and the East of Muntenia, hemodialysis and peritoneal
dialysis are mainly used and renal transplantation is rare.
12. The characteristics of the incident RRT Romanian patients are changing
and are converging to European incident patients characteristics: the
age and the proportions of patients with diabetes mellitus and cardiovascular comorbidities are increasing.
13. Nephrology care before initiating dialysis seems to be decient: the
proportion of patients without a known diagnosis of the primary kidney
dis-ease tends to decrease, but is still too high, which emphasizes the
need for programs addressing predialysis CKD patients.

14. There is no system for assessment of medical performance of the dialysis


centers. Collecting data on the medical performance at Romanian Renal
Registry would allow to obtain information for the quality assessment
and requires:
a. to establish compulsory reporting of the quality of therapy parameters
by the dialysis providers;
b. to properly reorganize and nance the Romanian Renal Registry, by
in-troducing a fee of 0.5% of the value of the contracts for dialysis
services.
15. The public sector in hospitals provides 11% of the dialysis services and its
existence is critical for the dialysis program. That is why it is necessary to:
a. redene rules for the deduction of dialysis sessions performed in
hospital at the initiation of therapy and for admitted dialysis patients;
b. introduce the health card for the patients in the program to facilitate
proper treatment records;
c. allocate around 5-10% of the program funds for these sessions.
16. Privatization allowed treating more patients by increasing the economic
eciency of the dialysis program. Practically, the costs per treated patient
decreased by 19% since 2004 until 2013. Unfortunately, the acquired
experience was not extended to other health programs.
17. The increase of the Leu/EURO exchange rate, the increase of the VAT, of
the cost of medicines (including the new medicines and peritoneal dialysis
solutions) and of the wages increased the costs of dialysis therapy. Since
the increase of expenses directly reects on the quality of therapy, it is
necessary to increase prices by 10-13% for hemodialysis and by 15-20%
for peritoneal dialysis.

51

Appendices
Appendix 1. The method for the calculation of the standardized mortality ratio

National reference mortality rates were calculated on a cohort of 11,829 hemodialysis patients alive on January 1st 2010, monitored over a 3-year period.
Patients who started hemodialysis 90 days before January 1st were excluded, and those who received renal transplantation or were no longer included in the
records in the observation period were censored.
As the major determinants of mortality are age and primary kidney disease (especially diabetic nephropathy), the national mortality rates were calculated by
8 age groups and 4 etiologies, including diabetes mellitus, in relation to the frequency of the primary kidney diseases reported in Romania)9.
By using these national rates, the expected number of deaths in a certain population can be calculated. The standardized mortality ratio is the ratio between
the expected number of deaths noticed in the respective population and the expected ratio. The European Renal Registry uses the same procedure for
comparisons.
The assessment of the survival rate by SMR is superior to the assessment of the crude mortality rate. However, the reference value is the national average
mortality rate, which does not necessarily correspond to an optimum care. On the other hand, due to the diversity and the multiple comorbidities of the
hemodialysis patients, the SMR must also be interpreted with care, as an orienting comparison. Thus, a center can provide an excellent care to a subgroup of
patients and a decient care to another subgroup, which would lead to a SMR of almost 1.00 by cancelling the two eects.
Accordingly, SMR is only an orienting parameter, which can indicate a care issue when the value is below 1, without allowing the identication of causes and
imposing additional analyses.

52

Appendix 2. The method of calculation of the survival rates

The data regarding the evolution of HD and PD patients were obtained from the Romanian Renal Registry, and those related to the survival of (preemptive
and non-preemptive) RT patients were obtained from the Fundeni Clinical Institute.
The data included 9,540 adult incident patients undergoing renal replacement therapy (HD, PD and RT) in the period 2008-2011 (4 years), with a total
monitoring period of 5 years: 01.01.2008-31.12.2012. The analysis used the renal replacement therapy method on day 91. The patients lost to follow-up were
censored. The characteristics of the investigated patients are presented in Table XV.
Table XV. The characteristics of the patients investigated for the survival analysis
Number of patients
Male (%)

Total

TR

HD

PD

9540

490

8050

1000

57

64

58

51

Primary kidney disease (%)


Glomerulonephritis
Tubule-interstitial nephritis
Hereditary nephropathies
Diabetic nephropathy
Renal vascular diseases
Unknown/ Others

17
12
6
14
7
44

42
9
6
7
1
35

16
12
6
14
7
14

16
13
5
17
12
37

Death causes (%)


Cardio-vascular
Neoplasia
Infectious
Gastrointestinal
Other causes/ unknown

48
3
3
2
44

17
41
34
8

48
3
3
2
44

47
2
2
1
48

p
<0,001
<0.001

<0.001

The unadjusted survival rates were calculated (Kaplan Meier), which were subsequently adjusted in a Cox logistic regression model.
53

Appendix 3. Dialysis centers, machines and patients treated on a machine in the counties of Romania in 2012, 2013 and variance 2013/2012 (in percentage)
County

Population

HD patients
2012

AB

342,376

Dialysis centers

2013

Variance

No

pmi

No

pmi

168

491

192

561

14.3%

2012

2013

HD machines
Variance

No

pmi

No

pmi

2.9

5.8

100.0%

2012

2013

Variance

No

pmi

Patients/
machine

No

pmi

Patients/
machine

39

114

4.3

40

116.8

4.8

Ap
2.6%

Variance
machine
11.4%

AG

612,431

283

462

312

509

10.2%

4.9

4.9

0.0%

59

96

4.8

73

119.2

4.3

23.7%

-10.9%

AR

430,629

179

416

187

434

4.5%

4.6

4.6

0.0%

30

70

6.0

35

81.3

5.3

16.7%

-10.5%

2,272,163

1,348

593

1,546

680

14.7%

21

9.2

20

8.8

-4.8%

329

145

4.1

393

173.0

3.9

19.5%

-4.0%

616,168

326

529

318

516

-2.5%

6.5

8.1

25.0%

63

102

5.2

70

113.6

4.5

11.1%

-12.2%

B + IF
BC
BH

575,398

351

610

351

610

0.0%

5.2

3.5

-33.3%

49

85

7.2

73

126.9

4.8

49.0%

-32.9%

BN

286,225

109

381

126

440

15.6%

7.0

7.0

0.0%

32

112

3.4

33

115.3

3.8

3.1%

12.1%

BR

321,212

199

620

199

620

0.0%

9.3

9.3

0.0%

56

174

3.6

67

208.6

3.0

19.6%

-16.4%

BT

412,626

219

531

227

550

3.7%

7.3

4.8

-33.3%

31

75

7.1

47

113.9

4.8

51.6%

-31.6%

BV

549,217

252

459

288

524

14.3%

9.1

9.1

0.0%

57

104

4.4

85

154.8

3.4

49.1%

-23.4%

BZ

451,069

139

308

156

346

12.2%

2.2

2.2

0.0%

31

69

4.5

31

68.7

5.0

0.0%

12.2%

CJ

691,106

435

629

454

657

4.4%

10.1

10.1

0.0%

122

177

3.6

119

172.2

3.8

-2.5%

7.0%

CL

306,691

76

248

84

274

10.5%

3.3

3.3

0.0%

21

68

3.6

21

68.5

4.0

0.0%

10.5%

CS

295,579

91

308

88

298

-3.3%

6.8

6.8

0.0%

29

98

3.1

32

108.3

2.8

10.3%

-12.4%

CT

684,082

304

444

330

482

8.6%

7.3

7.3

0.0%

76

111

4.0

86

125.7

3.8

13.2%

-4.1%

CV

210,177

43

205

90

428

109.3%

4.8

9.5

100.0%

17

81

2.5

18

85.6

5.0

5.9%

97.7%

DB

518,745

182

351

222

428

22.0%

5.8

5.8

0.0%

55

106

3.3

58

111.8

3.8

5.5%

15.7%

DJ

660,544

336

509

350

530

4.2%

4.5

4.5

0.0%

68

103

4.9

73

110.5

4.8

7.4%

-3.0%

GJ

341,594

196

574

208

609

6.1%

8.8

8.8

0.0%

58

170

3.4

68

199.1

3.1

17.2%

-9.5%

GL

536,167

114

213

124

231

8.8%

5.6

5.6

0.0%

38

71

3.0

39

72.7

3.2

2.6%

6.0%

GR

281,422

71

252

74

263

4.2%

3.6

3.6

0.0%

12

43

5.9

22

78.2

3.4

83.3%

-43.1%

HD

418,565

251

600

253

604

0.8%

9.6

9.6

0.0%

75

179

3.3

62

148.1

4.1

-17.3%

21.9%

HR

310,867

144

463

150

483

4.2%

12.9

12.9

0.0%

40

129

3.6

40

128.7

3.8

0.0%

4.2%

IL

274,148

90

328

101

368

12.2%

7.3

7.3

0.0%

29

106

3.1

28

102.1

3.6

-3.4%

16.2%

IS

772,348

446

577

499

646

11.9%

5.2

5.2

0.0%

102

132

4.4

102

132.1

4.9

0.0%

11.9%

MH

265,390

180

678

184

693

2.2%

7.5

7.5

0.0%

41

154

4.4

42

158.3

4.4

2.4%

-0.2%

MM

478,659

206

430

224

468

8.7%

6.3

6.3

0.0%

67

140

3.1

61

127.4

3.7

-9.0%

19.4%

MS

550,846

183

332

196

356

7.1%

5.4

5.4

0.0%

56

102

3.3

56

101.7

3.5

0.0%

7.1%

NT

470,766

262

557

268

569

2.3%

8.5

8.5

0.0%

62

132

4.2

63

133.8

4.3

1.6%

0.7%

54

County

Population

HD patients
2012

OT

436,400

Dialysis centers

2013

Variance

No

pmi

No

pmi

146

335

163

374

11.6%

2012

2013

HD machines
Variance

No

pmi

No

pmi

4.6

4.6

0.0%

2012

2013

Variance

No

pmi

Patients/
machine

No

pmi

Patients/
machine

27

62

5.4

35

80.2

4.7

Ap

Variance
machine

29.6%

-13.9%

PH

762,886

320

419

339

444

5.9%

3.9

5.2

33.3%

61

80

5.2

88

115.4

3.9

44.3%

-26.6%

SB

397,322

253

637

264

664

4.3%

10.1

10.1

0.0%

89

224

2.8

80

201.3

3.3

-10.1%

16.1%

SJ

224,384

88

392

99

441

12.5%

8.9

8.9

0.0%

19

85

4.6

19

84.7

5.2

0.0%

12.5%

SM

344,360

132

383

134

389

1.5%

5.8

5.8

0.0%

30

87

4.4

31

90.0

4.3

3.3%

-1.8%

SV

634,810

332

523

339

534

2.1%

6.3

6.3

0.0%

84

132

4.0

77

121.3

4.4

-8.3%

11.4%

TL

213,083

113

530

116

544

2.7%

9.4

9.4

0.0%

35

164

3.2

44

206.5

2.6

25.7%

-18.3%

TM

683,540

314

459

308

451

-1.9%

7.3

7.3

0.0%

94

138

3.3

73

106.8

4.2

-22.3%

26.3%

TR

380,123

147

387

159

418

8.2%

5.3

5.3

0.0%

33

87

4.5

33

86.8

4.8

0.0%

8.2%

VL

371,714

177

476

204

549

15.3%

8.1

8.1

0.0%

36

97

4.9

52

139.9

3.9

44.4%

-20.2%

VN

340,310

156

458

172

505

10.3%

5.9

5.9

0.0%

35

103

4.5

37

108.7

4.6

5.7%

4.3%

VS
Romania

395,499

190

480

224

566

17.9%

7.6

7.6

0.0%

59

149

3.2

59

149.2

3.8

0.0%

17.9%

20,121,641

9,551

475

10,322

513

8.1%

137

6.8

138

6.9

0.7%

2346

117

4.1

2565

127.5

4.0

9.3%

-1.2%

55

Appendix 4. Dialysis patients registered on 31.12.2012 and 31.12.2013 in the counties of Romania and the variance 2013/2012 (in percentage)
County

Population

HD patients
2012

2013

Variance

No

pmi

No

pmi

PD patients
2012

2013

Variance

No

pmi

No

pmi

Total
2012

2013

Variance

No

pmi

No

pmi

AB

342,376

168

491

192

561

14.3%

8.8

8.8

0.0%

171

499

195

569.5

14.0%

AG

612,431

283

462

312

509

10.2%

14

22.9

11

18.0

-21.4%

297

485

323

527.4

8.8%

AR

430,629

179

416

187

434

4.5%

16.3

7.0

-57.1%

186

432

190

441.2

2.2%

2,272,163

1,348

593

1,546

680

14.7%

166

73.1

157

69.1

-5.4%

1514

666

1703

749.5

12.5%

BC

616,168

326

529

318

516

-2.5%

29

47.1

26

42.2

-10.3%

355

576

344

558.3

-3.1%

BH

575,398

351

610

351

610

0.0%

11

19.1

21

36.5

90.9%

362

629

372

646.5

2.8%

BN

286,225

109

381

126

440

15.6%

0.0

0.0

0.0%

109

381

126

440.2

15.6%

BR

321,212

199

620

199

620

0.0%

32

99.6

30

93.4

-6.3%

231

719

229

712.9

-0.9%

BT

412,626

219

531

227

550

3.7%

14

33.9

13

31.5

-7.1%

233

565

240

581.6

3.0%

BV

549,217

252

459

288

524

14.3%

40

72.8

27

49.2

-32.5%

292

532

315

573.5

7.9%

BZ

451,069

139

308

156

346

12.2%

70

155.2

72

159.6

2.9%

209

463

228

505.5

9.1%

CJ

691,106

435

629

454

657

4.4%

10

14.5

11

15.9

10.0%

445

644

465

672.8

4.5%

CL

306,691

76

248

84

274

10.5%

0.0

0.0

0.0%

76

248

84

273.9

10.5%

CS

295,579

91

308

88

298

-3.3%

19

64.3

19

64.3

0.0%

110

372

107

362.0

-2.7%

CT

684,082

304

444

330

482

8.6%

30

43.9

21

30.7

-30.0%

334

488

351

513.1

5.1%

CV

210,177

43

205

90

428

109.3%

4.8

4.8

0.0%

44

209

91

433.0

106.8%

DB

518,745

182

351

222

428

22.0%

18

34.7

17

32.8

-5.6%

200

386

239

460.7

19.5%

DJ

660,544

336

509

350

530

4.2%

32

48.4

28

42.4

-12.5%

368

557

378

572.3

2.7%

GJ

341,594

196

574

208

609

6.1%

13

38.1

13

38.1

0.0%

209

612

221

647.0

5.7%

GL

536,167

114

213

124

231

8.8%

56

104.4

54

107.6

-3.6%

170

317

178

332.0

4.7%

GR

281,422

71

252

74

263

4.2%

0.0

0.0

0.0%

71

252

74

263.0

4.2%

HD

418,565

251

600

253

604

0.8%

9.6

14.3

50.0%

255

609

259

618.8

1.6%

HR

310,867

144

463

150

483

4.2%

3.2

3.2

0.0%

145

466

151

485.7

4.1%

IL

274,148

90

328

101

368

12.2%

29.2

21.9

-25.0%

98

357

107

390.3

9.2%

IS

772,348

446

577

499

646

11.9%

93

120.4

71

91.9

-23.7%

539

698

570

738.0

5.8%

MH

265,390

180

678

184

693

2.2%

12

45.2

15

56.5

25.0%

192

723

199

749.8

3.6%

MM

478,659

206

430

224

468

8.7%

16.7

12.5

-25.0%

214

447

230

480.5

7.5%

B + IF

56

County

Population

HD patients
2012

2013

Variance

No

pmi

No

pmi

PD patients
2012

2013

Variance

No

pmi

No

pmi

Total
2012

2013

Variance

No

pmi

No

pmi

MS

550,846

183

332

196

356

7.1%

12.7

16.3

28.6%

190

345

205

372.2

7.9%

NT

470,766

262

557

268

569

2.3%

17

36.1

10

21.2

-41.2%

279

593

278

590.5

-0.4%

OT

436,400

146

335

163

374

11.6%

18

41.2

13

29.8

-27.8%

164

376

176

403.3

7.3%

PH

762,886

320

419

339

444

5.9%

17

22.3

16

21.0

-5.9%

337

442

355

465.3

5.3%

SB

397,322

253

637

264

664

4.3%

23

57.9

22

55.4

-4.3%

276

695

286

719.8

3.6%

SJ

224,384

88

392

99

441

12.5%

0.0

0.0

0.0%

88

392

99

441.2

12.5%

SM

344,360

132

383

134

389

1.5%

29

84.2

27

78.4

-6.9%

161

468

161

467.5

0.0%

SV

634,810

332

523

339

534

2.1%

12.6

10

15.8

25.0%

340

536

349

549.8

2.6%

TL

213,083

113

530

116

544

2.7%

4.7

4.7

0.0%

114

535

117

549.1

2.6%

TM

683,540

314

459

308

451

-1.9%

16

23.4

27

39.5

68.8%

330

483

335

490.1

1.5%

TR

380,123

147

387

159

418

8.2%

11

28.9

10.5

-63.6%

158

416

163

428.8

3.2%

VL

371,714

177

476

204

549

15.3%

11

29.6

11

29.6

0.0%

188

506

215

578.4

14.4%

VN

340,310

156

458

172

505

10.3%

55

161.6

57

167.5

3.6%

211

620

229

672.9

8.5%

VS

395,499

190

480

224

566

17.9%

15

37.9

15

37.9

0.0%

205

518

239

604.3

16.6%

20,121,641

9,551

475

10,322

513

8.1%

919

45.7

854

42.4

-7.1%

10,470

520

11,176

555.4

6.7%

Romania

57

Appendix 5. Patients incident in hemodialysis (HD), peritoneal dialysis (PD), non-preemptive renal transplantation (TR) and the number of deaths in 2013 in the counties of Romania
County

Population

HD + PD patients
prevalent
patients**
Average

pmi

Newly included patients 2013


HD

PD

PD/HD

No

No

Deaths 2013

HD+DP
No

TR
pmi

No

No

pmi

pmi

AB

342,376

183

535.7

34

0.0

34

18.5

99.3

0.5

2.9

18

9.8

52.6

AG

612,431

316

515.3

27

3.7

28

8.9

45.7

0.3

1.6

45

14.3

73.5

AR

430,629

192

445.1

74

0.0

74

38.6

171.8

1.0

4.6

49

25.6

113.8

2,272,163

1,647

724.7

580

44

7.6

624

37.9

274.6

125

7.6

55.0

224

13.6

98.6

BC

616,168

350

568.0

37

11

29.7

48

13.7

77.9

1.7

9.7

52

14.9

84.4

BH

575,398

381

661.4

105

4.8

110

28.9

191.2

2.1

13.9

84

22.1

146.0

BN

286,225

119

416.9

35

0.0

35

29.3

122.3

2.5

10.5

23

19.3

80.4

B + IF

BR

321,212

235

731.3

54

16.7

63

26.8

196.1

0.0

0.0

26

11.1

80.9

BT

412,626

238

577.8

28

3.6

29

12.2

70.3

1.7

9.7

24

10.1

58.2

BV

549,217

312

568.4

82

3.7

85

27.2

154.8

1.9

10.9

37

11.9

67.4

BZ

451,069

222

492.7

34

10

29.4

44

19.8

97.5

0.0

0.0

29

13.0

64.3

CJ

691,106

459

663.7

84

2.4

86

18.8

124.4

1.1

7.2

50

10.9

72.3

CL

306,691

79

257.3

0.0

7.6

19.6

0.0

0.0

2.5

6.5

CS

295,579

110

372.7

66.7

10

9.1

33.8

1.8

6.8

27

24.5

91.3

CT

684,082

350

511.9

92

2.2

94

26.8

137.4

0.6

2.9

57

16.3

83.3

CV

210,177

65

306.9

15

6.7

16

24.8

76.1

1.6

4.8

10

15.5

47.6

DB

518,745

217

417.8

61

1.6

62

28.6

119.5

0.5

1.9

4.2

17.3

DJ

660,544

380

574.7

103

4.9

108

28.5

163.5

0.3

1.5

42

11.1

63.6

GJ

341,594

218

639.2

31

9.7

34

15.6

99.5

1.4

8.8

28

12.8

82.0

GL

536,167

176

329.0

20

12

60.0

32

18.1

59.7

1.1

3.7

27

15.3

50.4

GR

281,422

71

253.2

0.0

0.0

0.0

0.0

12

16.8

42.6

HD

418,565

256

610.4

88

3.4

91

35.6

217.4

1.6

9.6

34

13.3

81.2

HR

310,867

149

479.8

22

0.0

22

14.7

70.8

2.0

9.7

6.0

29.0

IL

274,148

102

372.1

18

0.0

18

17.6

65.7

0.0

0.0

6.9

25.5

IS

772,348

561

726.6

274

2.6

281

50.1

363.8

1.6

11.7

66

11.8

85.5

MH

265,390

197

742.0

36

2.8

37

18.8

139.4

1.5

11.3

31

15.7

116.8

MM

478,659

224

468.5

44

0.0

44

19.6

91.9

0.0

0.0

18

8.0

37.6

MS

550,846

199

361.9

18

0.0

18

9.0

32.7

1.5

5.4

14

7.0

25.4

58

County

Population

HD + PD patients
prevalent
patients**
Average

pmi

Newly included patients 2013


HD

PD

PD/HD

No

No

Deaths 2013

HD+DP
No

TR
pmi

No

No

pmi

pmi

NT

470,766

287

608.9

24

0.0

24

8.4

51.0

1.0

6.4

52

18.1

110.5

OT

436,400

171

391.7

30

10.0

33

19.3

75.6

0.0

0.0

28

16.4

64.2

PH

762,886

346

453.3

67

7.5

72

20.8

94.4

0.0

0.0

62

17.9

81.3

SB

397,322

285

717.5

67

4.5

70

24.6

176.2

2.1

15.1

38

13.3

95.6

SJ

224,384

91

407.0

28

0.0

28

30.7

124.8

1.1

4.5

18

19.7

80.2

SM

344,360

163

473.3

27

11.1

30

18.4

87.1

5.5

26.1

19

11.7

55.2

SV

634,810

350

550.8

133

0.0

133

38.0

209.5

0.0

0.0

56

16.0

88.2

TL

213,083

114

533.4

21

0.0

21

18.5

98.6

0.9

4.7

5.3

28.2

TM

683,540

334

489.2

65

7.7

70

20.9

102.4

2.7

13.2

50

15.0

73.1

TR

380,123

161

422.2

48

6.3

51

31.8

134.2

0.0

0.0

31

19.3

81.6

VL

371,714

209

562.3

44

11.4

49

23.4

131.8

1.0

5.4

26

12.4

69.9

VN

340,310

222

652.6

45

6.7

48

21.6

141.0

0.0

0.0

14

6.3

41.1

VS

395,499

226

572.1

37

0.0

37

16.4

93.6

0.4

2.5

33

14.6

83.4

20,121,641

10,966

545.0

2,644

155

5.9

2,799

25.5

139.1

227

2.1

11.3

1,487

13.6

73.9

Romania

*12 month average for the year 2012

59

Appendix 6. Prevalent patients in the dialysis centers in Romania on 31.12.2011 vs. 31.12.2010 and the variance 2012/2011 in percentage (in the alphabetical order of the counties)
Dialysis Center

County

Prevalent patients1
HD

PD

HD + PD

2012

2013

Variance

2012

2013

Variance

2012

2013

Variance2

1.

Nefromed Dialysis Centers Alba-Iulia

AB

168

186

10.7%

0.0%

171

189

10.5%

2.

Alba-Iulia County Emergency Hospital

AB

3.

FNC Pitesti

AG

167

179

7.2%

11

11

0.0%

178

190

6.7%

4.

Nefrocare CL - Cmpulung

AG

46

55

19.6%

46

55

19.6%

5.

Arges Pitesti County Hospital

AG

70

78

11.4%

-100.0%

73

78

6.8%

6.
7.

Hemo-Vest Arad
Arad County Clinical Emergency Hospital

AR
AR

149
30

157
30

5.4%
0.0%

6
1

3
0

-50.0%
-100.0%

155
31

160
30

3.2%
-3.2%

8.

IHS "Sf. Ioan" Bucharest

154

137

-11.0%

42

32

-23.8%

196

169

-13.8%

9.

CMDTAMP Bucharest

36

39

8.3%

36

39

8.3%

10.

FNC "Dr. Carol Davila" Bucharest

348

344

-1.1%

16

17

6.3%

364

361

-0.8%

11.

Fundeni Clinical Institute - Pediatric Dialysis

80.0%

-37.5%

13

14

7.7%

12.
13.

Fundeni Clinical Institute - Renal transplantation


"N. Paulescu Institute for Nutrition and Metabolic
Diseases

0.0%

0.0%

22

38

72.7%

10

-10.0%

32

47

46.9%

14.

IHS - "Sf. Pantelimon" Bucharest

118

136

15.3%

200.0%

120

140

16.7%

15.

IHS Fundeni

91

92

1.1%

43

43

0.0%

134

135

0.7%

16.

Diaverum Bucharest Industriilor

134

136

1.5%

18

12

-33.3%

152

148

-2.6%

17.

Diaverum Bucuresti - Splai Independentei

139

157

12.9%

0.0%

143

161

12.6%

18.

DIA MEDICAL PORT - Bucharest

50

101

102.0%

50

101

102.0%

19.

Gral Medical Bucharest

72

92

27.8%

72

88

22.2%

20.
21.

Nefro Care Center Bucuresti


Dr Carol Davila Clinical Nephrology Hospital - Bucharest

72

98

36.1%

-50.0%

76

99

30.3%

19

37

94.7%

12

11

-8.3%

31

47

51.6%

22.
23.

"Sf. Ioan" Clinical Emergency Hospital Bucharest


"Grigore Alexandrescu" Children Clinical Emergency
Hospital

28

21

-25.0%

28

21

-25.0%

24.

Floreasca Clinical Emergency Hospital Bucharest

15

11

-26.7%

0.0%

17

13

-23.5%

25.

Fundeni Clinical Hospital - Nephrology

25

400.0%

13

333.3%

38

375.0%

26.

"Marie Curie" Children Emergency Hospital Bucharest

14

13

60

Dialysis Center

County

Prevalent patients1
HD

PD

HD + PD

2012

2013

Variance

2012

2013

Variance

2012

2013

Variance2

27.

University Emergency Hospital Bucharest

32

51

59.4%

-50.0%

34

52

52.9%

28.

FNC Bacau

BC

200

205

2.5%

29

26

-10.3%

229

231

0.9%

29.

MALP Moinesti - Dialysis station

BC

36

36

30.

Renal Med Bacau Onesti

BC

61

60

-1.6%

61

60

-1.6%

31.
32.

Bacau County Emergency Hospital


Moinesti Dialysis station

BC
BC

26
39

17
0

-34.6%
-100.0%

0
0

0
0

26
39

17
0

-34.6%
-100.0%

33.

FNC Oradea

BH

194

194

0.0%

194

194

0.0%

34.

Renamed Nefrodial Oradea

BH

157

157

0.0%

11

21

90.9%

168

178

6.0%

35.

Diaverum Bistrita

BN

85

97

14.1%

85

97

14.1%

36.

Bistrita Nasaud County Emergency Hospital

BN

24

29

20.8%

24

29

20.8%

37.

IHS Braila

BR

125

126

0.8%

31

30

-3.2%

156

156

0.0%

38.

Specimed Braila

BR

57

65

14.0%

57

65

14.0%

39.

Braila County Emergency Hospital

BR

17

-52.9%

-100.0%

18

-55.6%

40.

Avitum Botosani

BT

135

225

66.7%

13

333.3%

138

238

72.5%

41.

Nefromed Dialysis Centers Botosani

BT

84

-100.0%

11

-100.0%

95

-100.0%

42.

"Mavromati" County Hospital Botosani

BT

43.

FNC Brasov

BV

160

178

11.3%

38

22

-42.1%

198

200

1.0%

44.

Arnaldo Medical Clinic Brasov

BV

74

92

24.3%

74

94

27.0%

45.

Brasov County Clinical Emergency Hospital

BV

-50.0%

-100.0%

-60.0%

46.

Fagaras Town Hospital

BV

14

16

14.3%

0.0%

15

17

13.3%

47.

"ERIKA Haemodialysis station Brasov

BV

48.

IHS Buzau

BZ

139

156

12.2%

70

72

2.9%

209

228

9.1%

49.

NEFROCARE DJ Dej

CJ

33

37

12.1%

33

37

12.1%

50.

Potaissa Renal Care - Turda

CJ

76

86

13.2%

76

86

13.2%

51.

Rena Clinic Cluj

CJ

84

91

8.3%

84

91

8.3%

52.

Nefromed Hemodialysis Centers Cluj

CJ

188

192

2.1%

10

11

10.0%

198

203

2.5%

61

Dialysis Center

County

Prevalent patients1
HD
2012

2013

PD

HD + PD

Variance

2012

2013

Variance

2012

2013

Variance2

53.

Cluj Children Clinical Emergency Hospital - Nephrology Department

CJ

54.

Cluj County Clinical Emergency Hospital

CJ

17

-64.7%

17

-64.7%

55.

Cluj-Napoca Town Clinical Hospital

CJ

37

40

8.1%

37

40

8.1%

56.

IHS Calarasi

CL

76

84

10.5%

76

84

10.5%

57.

VAMAGO Resita

CS

87

82

-5.7%

17

16

-5.9%

104

98

-5.8%

58.

Caras Severin County Hospital - Resita

CS

50.0%

50.0%

50.0%

59.

FNC Constanta

CT

158

164

3.8%

0.0%

161

167

3.7%

60.

Nefrocare Med Medgidia

CT

42

42

0.0%

-40.0%

47

45

-4.3%

61.

IHS Constanta

CT

20

23

15.0%

-33.3%

26

27

3.8%

62.

Eurodializa Mangalia

CT

27

33

22.2%

27

33

22.2%

63.

Constanta County Clinical Emergency Hospital

CT

57

68

19.3%

16

11

-31.3%

73

79

8.2%

64.
65.

Avitum Sf. Gheorghe


"Dr. Fogolyan Kristof" County Emergency Hospital
Covasna

CV

43

84

95.3%

0.0%

44

85

93.2%

CV

66.

Diasys Medical Targoviste

DB

69

74

7.2%

69

74

7.2%

67.

Renal Care Group Targoviste

DB

97

120

23.7%

-11.1%

106

127

19.8%

68.

Dambovita County Emergency Hospital Targoviste

DB

16

28

75.0%

0.0%

25

37

48.0%

69.

IHS Craiova

DJ

83

102

22.9%

24

22

-8.3%

107

124

15.9%

70.

Renamed Dialcare- Craiova

DJ

190

202

6.3%

190

202

6.3%

71.

Craiova County Clinical Emergency Hospital

DJ

63

46

-27.0%

-25.0%

71

52

-26.8%

72.

Avitum Targu-Jiu

GJ

137

145

5.8%

-11.1%

146

153

4.8%

73.

Targu Jiu County Emergency Hospital

GJ

74.

Diaverum Tg. Jiu

GJ

59

61

3.4%

25.0%

63

66

4.8%

75.

IHS Galati

GL

87

97

11.5%

49

50

2.0%

136

147

8.1%

76.
77.

"Sf. Ioan" Clinical Children Emergency Hospital Galati


"Sf. Ap. Andrei" County Clinical Emergency Hospital
Galati

GL

-12.5%

-12.5%

GL

19

20

5.3%

-42.9%

26

24

-7.7%

62

Dialysis Center

County

Prevalent patients1
HD

PD

HD + PD

2012

2013

Variance

2012

2013

Variance

2012

2013

Variance2

78.

Renal Care Group Giurgiu

GR

71

74

4.2%

71

74

4.2%

79.

FNC Deva

HD

134

136

1.5%

134

136

1.5%

80.

IHS Petrosani

HD

60

64

6.7%

200.0%

61

66

8.2%

81.

Hunedoara Deva County Emergency Hospital

HD

34

36

5.9%

34

36

5.9%

82.

"Wolfgan Steger Emergency Hospital Petrosani

HD

23

17

-26.1%

0.0%

26

20

-23.1%

83.

Diaverum Miercurea Ciuc

HR

95

100

5.3%

95

100

5.3%

84.

Diaverum Odorheiu Secuiesc

HR

47

48

2.1%

0.0%

48

49

2.1%

85.

Harghita County Emergency Hospital Miercurea Ciuc

HR

100.0%

100.0%

86.

Odorheiu Secuiesc Town Hospital

HR

-100.0%

-100.0%

87.

Renal Care Group Slobozia

IL

80

92

15.0%

-25.0%

88

97

10.2%

88.

Ialomita County Emergency Hospital Slobozia

IL

10

-10.0%

10

-10.0%

89.

FNC - C.I. Parhon Clinical Hospital No. 2 Iasi

IS

216

240

11.1%

54

39

-27.8%

270

279

3.3%

90.

NEFROCARE MS Iasi

IS

202

224

10.9%

31

24

-22.6%

233

247

6.0%

91.

"Dr. C. I. Parhon" Clinical Hospital

IS

20

26

30.0%

20

26

30.0%

92.

"Sf. Maria" Clinical Children Emergency Hospital Iasi

IS

12.5%

0.0%

16

17

6.3%

93.

Renamed Medical Service IITurnu Severin

MH

166

174

4.8%

12

15

25.0%

178

189

6.2%

94.

Drobeta Turnu-Severin Railway Hospital

MH

14

10

-28.6%

14

10

-28.6%

95.

NEFROCARE SIG Sighetu Marmatiei

MM

56

64

14.3%

56

64

14.3%

96.

Nefromed Dialysis Centers Baia Mare

MM

83

89

7.2%

-14.3%

90

95

5.6%

97.

Baia Mare County Emergency Hospital

MM

67

71

6.0%

-100.0%

68

71

4.4%

98.

Avitum Sighisoara

MS

34

40

17.6%

34

41

20.6%

99.

Avitum Tg. Mures

MS

116

117

0.9%

14.3%

123

125

1.6%

100.

HIPARION MED Tg. Mures

MS

33

39

18.2%

33

39

18.2%

101.

Diaverum Roman

NT

62

67

8.1%

50.0%

64

70

9.4%

102.

MEDISS CENTER - Targu Neamt

NT

62

68

9.7%

-25.0%

66

71

7.6%

103.

Nefromed Dialysis Centers Piatra Neamt

NT

135

132

-2.2%

11

-63.6%

146

136

-6.8%

63

Dialysis Center

County

Prevalent patients1
HD
2012

PD

2013

Variance

2012

2013

HD + PD
Variance

2012

2013

Variance2

104.

Neamt County Emergency Hospital Piatra Neamt

NT

-66.7%

-66.7%

105.

Nefrolab Slatina

OT

108

137

26.9%

100.0%

110

141

28.2%

106.

Olt Slatina County Emergency Hospital

OT

38

26

-31.6%

16

-43.8%

54

35

-35.2%

107.

IHS Busteni

PH

11

14

27.3%

11

14

27.3%

108.

PREMIUM MEDICAL CLINIC Ploiesti

PH

56

56

109.

Nefroclinic Ploiesti

PH

206

198

-3.9%

17

16

-5.9%

223

214

-4.0%

110.

Prahova County Emergency Hospital Ploiesti

PH

103

71

-31.1%

103

71

-31.1%

111.

Diaverum Medias

SB

47

51

8.5%

16.7%

53

58

9.4%

112.

Diaverum Sibiu

SB

153

157

2.6%

-16.7%

159

162

1.9%

113.

Diaverum Sibiu

SB

47

49

4.3%

11

10

-9.1%

58

59

1.7%

114.

Sibiu County Clinical Emergency Hospital

SB

16.7%

16.7%

115.

NEFROMED SJ Zalau

SJ

84

95

13.1%

84

95

13.1%

116.

Salaj Zalau County Hospital

SJ

0.0%

0.0%

117.

Nefromed Dialysis Centers Satu Mare

SM

118

124

5.1%

29

27

-6.9%

147

151

2.7%

118.

Satu Mare County Hospital

SM

14

10

-28.6%

14

10

-28.6%

119.

Avitum Suceava

SV

121

123

1.7%

121

125

3.3%

120.

FNC Suceava

SV

145

153

5.5%

0.0%

152

160

5.3%

121.
122.

NEFROMED BM Radauti
"Sf. Ioan cel Nou" County Emergency Hospital Suceava

SV

48

53

10.4%

0.0%

49

52

6.1%

SV

18

10

-44.4%

18

10

-44.4%

123.

Renal Care Group Tulcea

TL

85

81

-4.7%

0.0%

86

82

-4.7%

124.

Tulcea County Emergency Hospital

TL

28

35

25.0%

28

35

25.0%

125.

Avitum Timisoara

TM

92

107

16.3%

33.3%

98

115

17.3%

126.
127.
128.

Nefromed Dialysis Center Timisoara


"Louis Turcanu" Children Emergency Hospital
Timis County Hospital and Renal transplantation Clinic Timisoara

TM
TM

181
0

170
0

-6.1%
-

8
1

16
0

100.0%
-100.0%

189
1

186
0

-1.6%
-100.0%

TM

23

16

-30.4%

23

17

-26.1%

129.

Lugoj Town Hospital - Dialysis station

TM

18

15

-16.7%

100.0%

19

17

-10.5%

130.

Nefromed Dialysis Centers Alexandria

TR

128

137

7.0%

128

137

7.0%

64

Dialysis Center

County

Prevalent patients1
HD

PD

HD + PD

2012

2013

Variance

2012

2013

Variance

2012

2013

Variance2

131.

Teleorman County Hospital - Alexandria

TR

19

22

15.8%

11

-63.6%

30

26

-13.3%

132.

IHS Ramnicu Valcea

VL

100.0%

100.0%

133.

RENAMED NEFRODIAMED Ramnicu Valcea

VL

134

158

17.9%

134

158

17.9%

134.

Valcea County Hospital Ramnicu Valcea

VL

43

46

7.0%

-37.5%

51

51

0.0%

135.
136.

IHS Focsani
"Sf. Pantelimon" Vrancea County Emergency Hospital,
Focsani

VN

144

161

11.8%

54

55

1.9%

198

216

9.1%

VN

12

11

-8.3%

100.0%

13

13

0.0%

137.

Med Center Clinic Vaslui

VS

82

103

25.6%

15

-40.0%

97

111

14.4%

138.

Nefromed Dialysis Centers Barlad

VS

105

110

4.8%

105

116

10.5%

139.

"Elena Beldiman" Barlad Town Emergency Hospital

VS

11

266.7%

11

266.7%

10.470

11.158

6.6%

Romania
1
2

9.551

10.322

8.1%

919

854

-7.1%

- Patients registered on 31.12.2012 and 31.12.2013


- Variance in percentage 31.12.2013 vs. 31.12.2012

65

Appendix 7. Prevalent and incident dialysis patients, non-preemptive transplanted or deceased patients in dialysis centers in Romania in 2013 (in the alphabetical order of the counties)
Dialysis center

County

Prevalent patients*
HD

PD

Newly-included patients

PD/HD HD+DP HD
%

PD

PD/HD

Deaths

HD+DP

TR

No

No

No

No

No

No

No

1.
2.

Nefromed Dialysis Centers - Alba-Iulia


Alba-Iulia County Emergency Hospital - Haemodialysis department

AB

178

1.7%

181

11

0.0%

11

6.1%

No
1

0.6%

18

%
9.9%

AB

0.0%

23

0.0%

23

920.0%

0.0%

0.0%

3.

Fresenius NephroCare Pitesti

AG

178

10

5.7%

188

0.0%

0.0%

23

12.3%

4.

Nefrocare CL - Campulung

AG

50

0.0%

50

0.0%

2.0%

12.0%

5.

Arges - Pitesti County Hospital

AG

77

0.8%

78

27

3.7%

28

36.1%

0.0%

16

20.6%

6.

Hemo-Vest - Arad

AR

156

3.1%

161

0.0%

1.2%

21

13.1%

7.

Arad County Clinical Emergency Hospital

AR

31

0.8%

31

74

0.0%

74

240.7%

0.0%

28

91.1%

8.

IHS "Sf. Ioan" Bucharest

153

37

24.4%

191

133.3%

3.7%

0.0%

28

14.7%

9.

CMDTAMP Bucharest

38

0.2%

38

100.0%

5.3%

0.0%

13.2%

10.

Fresenius NephroCare "Dr. Carol Davila - Bucharest

347

16

4.5%

362

0.0%

0.8%

13

3.6%

11.

Fundeni Clinical Institute - Pediatric Dialysis

97.8%

15

0.0%

13.2%

0.0%

0.0%

12.
13.

Fundeni Clinical Institute - Renal transplantation


"N. Paulescu Institute for Nutrition and Metabolic
Diseases

0.0%

49

0.0%

49

612.5% 112 1400.0%

0.0%

35

22.9%

43

36

13.9%

41

95.5%

0.0%

11

25.6%

14.

IHS - "Sf. Pantelimon" Bucharest

127

3.2%

131

0.0%

1.5%

1.5%

17

13.0%

15.

IHS Fundeni

87

44

50.8%

131

0.0%

0.8%

0.8%

6.9%

16.

Diaverum - Bucharest Industriilor

132

14

10.3%

146

0.0%

1.4%

15

10.3%

17.

Diaverum - Bucuresti - Splai Independentei

151

2.9%

155

0.0%

0.0%

20

12.9%

18.

DIA MEDICAL PORT - Bucharest

80

0.0%

80

0.0%

5.0%

8.7%

19.

Gral Medical - Bucharest

87

0.0%

87

0.0%

0.0%

0.0%

20.
21.

Nefro Care Center - Bucharest


"Dr. Carol Davila" Clinical Nephrology Hospital Bucharest

93

3.9%

97

0.0%

0.0%

9.3%

32

12

37.7%

44

172

16

9.3%

188

428.9%

0.0%

11

25.1%

22.
23.

"Sf. Ioan" Clinical Emergency Hospital Bucharest


"Grigore Alexandrescu" Children Clinical Emergency
Hospital

18

0.0%

18

110

0.0%

110

614.0%

0.0%

20

111.6%

24.

Floreasca Clinical Emergency Hospital Bucharest

17

23.0%

21

24

4.2%

25

119.5%

4.8%

11

52.6%

25.

Fundeni Clinical Institute - Nephrology

11

12 109.1%

23

43

14

32.6%

57

247.8%

0.0%

17.4%

66

Dialysis center

County

Prevalent patients*
HD

PD

No

No

10

SUUB University Emergency Hospital Bucharest

Fresenius NephroCare Bacau

BC

26.

"Marie Curie" Children Emergency Hospital Bucharest

27.
28.

Newly-included patients

PD/HD HD+DP HD

PD

PD/HD

Deaths

HD+DP

TR

No

No

No

No

No

No

0.0%

10

0.0%

40.0%

0.0%

0.0%

44

4.6%

46

133

2.3%

136

298.9%

0.0%

44

96.7%

202

28

14.0%

230

14

7.1%

15

6.5%

2.6%

32

13.9%

29.

MALP Moinesti

BC

0.0%

0.0%

0.0%

11.0%

30.

Renal Med Bacau- Onesti

BC

61

0.0%

61

0.0%

3.3%

0.0%

8.2%

31.

Bacau County Emergency Hospital

BC

19

5.8%

20

19

10

52.6%

29

147.5%

0.0%

25.4%

32.

Moinesti Dialysis station

BC

30

0.0%

30

0.0%

6.7%

0.0%

30.2%

33.

Fresenius NephroCare Oradea

BH

198

0.0%

198

53

0.0%

53

26.8%

1.5%

51

25.8%

34.

Renamed Nefrodial - Oradea

BH

164

19

11.5%

183

52

9.6%

57

31.1%

2.7%

33

18.0%

35.

Diaverum - Bistrita

BN

94

0.0%

94

0.0%

3.2%

13

13.8%

36.

Bistrita Nasaud County Emergency Hospital

BN

25

0.0%

25

35

0.0%

35

141.9%

0.0%

10

40.5%

37.

IHS Braila

BR

127

32

24.8%

159

0.6%

0.0%

10

6.3%

38.

Specimed Braila

BR

61

0.0%

61

0.0%

0.0%

0.0%

39.

Braila County Emergency Hospital

BR

14

6.0%

15

54

14.8%

62

418.0%

0.0%

16

107.9%

40.

Avitum Botosani

BT

208

12

5.8%

220

0.0%

1.8%

1.8%

22

10.0%

41.

Nefromed Dialysis Centers - Botosani

BT

13

13.8%

15

0.0%

0.0%

13.2%

42.

"Mavromati" County Hospital Botosani

BT

0.0%

24

4.2%

25

833.3%

0.0%

0.0%

43.

Fresenius NephroCare Brasov

BV

170

29

16.9%

198

0.0%

1.5%

3.0%

20

10.1%

44.

Arnaldo Medical Clinic Brasov

BV

88

2.3%

90

17

11.8%

19

21.1%

0.0%

4.4%

45.

Brasov County Clinical Emergency Hospital

BV

1.2%

61

1.6%

62

907.3%

0.0%

102.4%

46.

Fagaras Town Hospital

BV

16

6.3%

17

0.0%

5.9%

0.0%

35.3%

47.

"ERIKA Haemodialysis station Brasov

BV

48.

IHS - Buzau

BZ

150

73

48.7%

223

34

10

29.4%

44

19.7%

0.0%

29

13.0%

49.

NEFROCARE DJ - Dej

CJ

37

0.0%

37

0.0%

2.7%

18.7%

50.

Potaissa Renal Care - Turda

CJ

82

0.0%

82

0.0%

3.7%

0.0%

12

14.7%

51.

Rena Clinic Cluj

CJ

92

0.0%

92

0.0%

2.2%

0.0%

52.

Nefromed Hemodialysis Centers - Cluj

CJ

186

11

5.8%

197

0.0%

1.0%

27

13.7%

53.

Cluj Children Clinical Emergency Hospital

CJ

0.0%

100.0%

100.0%

0.0%

0.0%

54.

Cluj County Clinical Emergency Hospital

CJ

10

0.9%

10

76

1.3%

77

796.6%

0.0%

0.0%

67

Dialysis center

County

Prevalent patients*
HD

PD

No

No

Newly-included patients

PD/HD HD+DP HD

PD

PD/HD

No

No

No

Deaths

HD+DP

TR

No

No

No

55.

Cluj-Napoca Town Clinical Hospital

CJ

39

0.4%

39

0.0%

10.2%

0.0%

10.2%

56.

IHS Calarasi

CL

79

0.0%

79

0.0%

7.6%

0.0%

2.5%

57.

VAMAGO - Resita

CS

85

16

18.9%

102

50.0%

3.0%

2.0%

18

17.7%

58.

Caras Severin County Hospital - Resita

CS

35.5%

75.0%

81.6%

0.0%

104.9%

59.

Fresenius NephroCare Constanta

CT

161

2.2%

165

0.0%

0.6%

10

6.1%

60.

Nefrocare Med - Medgidia

CT

43

8.4%

46

0.0%

0.0%

11

23.8%

61.

IHS Constanta

CT

23

21.2%

28

0.0%

3.6%

7.1%

62.

Eurodializa - Mangalia

CT

34

0.0%

34

0.0%

0.0%

8.8%

63.

Constanta County Clinical Emergency Hospital

CT

65

12

18.9%

77

92

2.2%

94

122.6%

0.0%

31

40.4%

64.
65.

Avitum - Sf. Gheorghe


"Dr. Fogolyan Kristof" County Emergency Hospital
Covasna

CV

62

1.6%

63

0.0%

8.0%

1.6%

11.1%

CV

6.3%

10

10.0%

11

776.5%

0.0%

211.8%

66.

Diasys Medical - Targoviste

DB

69

0.0%

69

0.0%

0.0%

11.5%

67.

Renal Care Group - Targoviste

DB

113

8.0%

122

0.0%

0.8%

0.0%

68.

Dambovita County Emergency Hospital Targoviste

DB

17

50.5%

25

61

1.6%

62

244.7%

0.0%

3.9%

69.

IHS Craiova

DJ

93

22

23.7%

115

0.0%

0.0%

17

14.7%

70.

Renamed Dialcare - Craiova

DJ

200

0.0%

200

0.0%

0.5%

2.5%

71.

Craiova County Clinical Emergency Hospital

DJ

57

11.9%

63

103

4.9%

108

170.3%

0.0%

20

31.5%

72.

Avitum - Targu-Jiu

GJ

143

6.2%

152

20

10.0%

22

14.5%

0.7%

23

15.1%

73.

Diaverum - Tg. Jiu

GJ

62

5.6%

66

0.0%

3.1%

7.6%

74.

Targu Jiu County Emergency Hospital

GJ

0.0%

11

0.0%

11 1100.0%

0.0%

0.0%

75.

Dialysis station of the Tg. Carbunesti Town Hospital

GJ

1 1200.0%

0.0%

0.0%

76.

IHS Galati

GL

93

49

52.2%

142

0.0%

0.7%

16

11.3%

77.
78.

"Sf. Ioan" Clinical Children Emergency Hospital Galati GL


"Sf. Ap. Andrei" County Clinical Emergency Hospital
Galati
GL

5.6%

0.0%

12.8%

0.0%

21

26.7%

27

20

12

60.0%

32

120.8%

0.0%

11

41.5%

79.

Renal Care Group - Giurgiu

GR

71

0.0%

71

0.0%

0.0%

12

16.8%

80.

Fresenius NephroCare Deva

HD

135

0.0%

135

0.0%

0.7%

19

14.1%

81.

IHS Petrosani

HD

63

3.2%

65

0.0%

3.1%

14.0%

82.

Hunedoara County Emergency Hospital - Deva

HD

36

0.0%

36

56

0.0%

56

155.6%

0.0%

0.0%

83.

"Wolfgan Steger Emergency Hospital Petrosani

HD

18

14.6%

20

32

9.4%

35

172.8%

4.9%

29.6%

68

Dialysis center

County

Prevalent patients*
HD

PD

No

No

Newly-included patients

PD/HD HD+DP HD
%

PD

PD/HD

No

No

No

Deaths

HD+DP

TR

No

No

No

84.

Diaverum - Miercurea Ciuc

HR

101

0.0%

101

0.0%

1.0%

2.0%

85.

Diaverum - Odorheiu Secuiesc

HR

45

2.0%

46

0.0%

4.3%

13.0%

86.

Harghita County Emergency Hospital Miercurea Ciuc

HR

0.0%

17

0.0%

17 1020.0%

0.0%

0.0%

87.

Odorheiu Secuiesc Town Hospital

HR

0.0%

0.0%

5 1000.0%

0.0%

200.0%

88.

Renal Care Group Slobozia

IL

86

6.4%

91

0.0%

0.0%

7.7%

89.

Ialomita County Emergency Hospital Slobozia

IL

11

0.0%

11

18

0.0%

18

167.4%

0.0%

0.0%

90.

Fresenius NephroCare - CI Parhon Iasi

IS

230

47

20.3%

276

83.3%

11

4.0%

1.4%

33

12.0%

91.

NEFROCARE MS Iasi

IS

215

27

12.7%

242

0.0%

0.8%

2.1%

11

4.5%

92.

"Dr. C. I. Parhon" Clinical Hospital Iasi

IS

26

0.3%

26

261

0.4%

262 1010.9%

0.0%

21

81.0%

93.

"Sf. Maria" Clinical Children Emergency Hospital Iasi

IS

91.4%

17

20.0%

35.8%

0.0%

6.0%

94.

Renamed Medical Service II - Turnu Severin

MH

172

14

8.1%

186

36

2.8%

37

19.9%

1.6%

26

14.0%

95.

Drobeta Turnu-Severin Railway Hospital

MH

11

0.8%

11

0.0%

0.0%

46.5%

96.

NEFROCARE SIG - Sighetu Marmatiei

MM

61

0.0%

61

0.0%

0.0%

3.3%

97.

Nefromed Dialysis Centers - Baia Mare

MM

85

7.9%

91

0.0%

1.1%

0.0%

3.3%

98.

Baia Mare County Emergency Hospital

MM

72

0.0%

72

43

0.0%

43

59.6%

0.0%

13

18.0%

99.

Avitum - Sighisoara

MS

38

0.7%

38

0.0%

13.2%

2.6%

7.9%

100.

Avitum Tg. Mures

MS

118

6.1%

125

0.0%

4.8%

0.8%

6.4%

101.

HIPARION MED Targu Mures

MS

37

0.0%

37

0.0%

19.0%

2.7%

8.1%

102.

Diaverum - Roman

NT

64

4.2%

67

0.0%

0.0%

13.5%

103.

MEDISS CENTER - Targu Neamt

NT

71

4.9%

75

0.0%

1.3%

16

21.5%

104.

Nefromed Dialysis Centers - Piatra Neamt

NT

135

4.6%

141

0.0%

0.7%

1.4%

16

11.3%

105.

Neamt County Emergency Hospital - Piatra Neamt

NT

0.0%

23

0.0%

23

766.7%

0.0%

11

366.7%

106.

Nefrolab - Slatina

OT

129

2.6%

133

0.0%

0.8%

0.0%

17

12.8%

107.

Olt Slatina County Emergency Hospital

OT

28

11

38.7%

39

29

10.3%

32

82.4%

0.0%

11

28.3%

108.

IHS Busteni

PH

12

0.0%

12

0.0%

0.0%

8.3%

109.

PREMIUM MEDICAL CLINIC - Ploiesti

PH

37

0.0%

37

0.0%

0.0%

24.5%

110.

Nefroclinic - Ploiesti

PH

199

17

8.6%

216

1.4%

0.0%

22

10.2%

111.

Prahova County Emergency Hospital Ploiesti

PH

81

0.2%

81

67

3.0%

69

85.5%

0.0%

30

37.2%

112.

Diaverum - Medias

SB

47

16.4%

55

3.6%

0.0%

10

18.2%

113.

Diaverum - Sibiu

SB

159

3.0%

163

0.0%

3.1%

11

6.7%

69

Dialysis center

County

Prevalent patients*
HD

PD

No

No

Newly-included patients

PD/HD HD+DP HD
%

PD

PD/HD

No

No

No

Deaths

HD+DP

TR

No

No

No

114.

Diaverum Sibiu

SB

47

11

23.3%

58

0.0%

1.7%

3.5%

115.

Sibiu County Clinical Emergency Hospital

SB

0.9%

67

1.5%

68

762.6%

0.0%

15

168.2%

1.1%

1.1%

14

15.8%

27 1012.5%

0.0%

150.0%

116.

NEFROMED SJ - Zalau

SJ

89

0.0%

89

0.0%

117.

Salaj - Zalau County Hospital

SJ

0.0%

27

0.0%

118.

Nefromed Dialysis Centers - Satu Mare

SM

122

28

22.9%

150

0.0%

2.0%

2.7%

4.7%

119.

Satu Mare County Hospital

SM

12

2.0%

13

24

12.5%

27

214.6%

39.7%

12

95.4%

120.

Avitum - Suceava

SV

120

1.1%

122

0.0%

0.0%

18

14.8%

121.

Fresenius NephroCare Suceava

SV

152

4.9%

159

0.0%

0.6%

0.0%

3.1%

122.
123.

NEFROMED BM - Radauti
"Sf. Ioan cel Nou" County Emergency Hospital Suceava

SV

54

1.9%

55

0.0%

0.0%

5.5%

SV

14

0.0%

14

132

0.0%

132

937.3%

0.0%

30

213.0%

124.

Renal Care Group Tulcea

TL

83

1.2%

84

0.0%

1.2%

7.1%

125.

Tulcea County Emergency Hospital

TL

30

0.0%

30

21

0.0%

21

70.8%

0.0%

0.0%

126.

Avitum - Timisoara

TM

101

6.7%

108

100.0%

1.9%

0.9%

16

14.8%

127.

Nefromed Dialysis Center - Timisoara

TM

174

13

7.5%

187

1.1%

1.1%

18

9.6%

128.

"Louis Turcanu" Children Emergency Hospital

TM

129.

Timis County Hospital

TM

19

4.5%

19

62

3.2%

64

329.6%

30.9%

16

82.4%

130.

Lugoj Town Hospital

TM

18

6.8%

20

0.0%

10.3%

0.0%

0.0%

131.

Nefromed Dialysis Centers - Alexandria

TR

132

0.0%

132

0.0%

0.0%

28

21.2%

132.

Teleorman County Hospital Alexandria

TR

20

42.9%

29

48

6.3%

51

178.4%

0.0%

10.5%

133.

IHS - Ramnicu Valcea

VL

80.0%

0.0%

0.0%

134.

RENAMED NEFRODIAMED - Ramnicu Valcea

VL

152

0.0%

152

0.0%

1.3%

17

11.2%

135.

Vlcea County Hospital - Rmnicu Vlcea

VL

45

15.1%

52

44

2.3%

45

87.4%

0.0%

17.5%

136.
137.

IHS Focsani
VN
County Emergency Hospital "Sf. Pantelimon" Vrancea
- Focsani
VN

149

53

35.7%

202

0.0%

0.0%

13

6.4%

18

11.1%

20

45

6.7%

48

240.0%

0.0%

5.0%

138.

Med Center Clinic - Vaslui

VS

94

12

12.3%

106

0.0%

0.9%

8.5%

139.
140.

Nefromed Dialysis Centers Barlad


"Elena Beldiman" Emergency Hospital of the Town
Barlad

VS

109

5.5%

115

0.0%

0.0%

18

15.7%

37

0.0%

37

792.9%

0.0%

128.6%

10900 2.644 155

5.9%

2.799

2.1% 1.487

13.6%

Romania

VS

0.0%

10.022

878

8.8%

25.7% 227

* Monthly average of prevalent patients in 2013

70

Appendix 8. Haemodialysis centers ordered increasingly by the standardized mortality ratio (SMR)

Prevalent
patients*

SMR

CI 95%

130

0.39

0.15

0.62 Low

Valcea County Hospital - Dialysis center Ramnicu Valcea

36

0.35

-0.05

0.74 Low

S.C. NEFROCARE SIG S.R.L. - Dialysis center Sighetu Marmatiei

47

0.29

-0.01

0.59 Low

Potaissa Renal Care - Turda - Dialysis center

45

0.27

0.54 Low

Rena Clinic Cluj

76

0.14

0.04

0.25 Low

Renal Care Group - Dialysis center Targoviste

94

0.13

0.04

0.23 Low

154

0.58

0.25

0.9 Low

International Healthcare Systems S.A - "Sf. Pantelimon" Bucharest

92

0.56

0.15

0.96 Low

S.C. Nefrolab S.R.L. - Dialysis center Slatina

87

0.56

0.15

0.96 Low

167

0.49

0.21

0.76 Low

49

0.49

0.02

0.96 Low

327

0.62

0.38

0.86 Low

Olt County Emergency Hospital - Haemodialysis center Slatina

35

5.45

-1.22

12.12 Similar

Hunedoara County Emergency Hospital - Dialysis center Deva

26

0.44

-0.14

1.02 Similar

S.C. Med Center Clinic SRL Vaslui

68

0.57

0.08

1.05 Similar

SC Diaverum Romania SRL - Miercurea Ciuc Unit

89

0.59

0.15

1.04 Similar

International Healthcare Systems S.A. - Dialysis center Braila

98

0.63

0.19

1.08 Similar

117

0.65

0.23

1.07 Similar

38

0.67

-0.09

1.44 Similar

152

0.69

0.29

1.1 Similar

SC Diaverum Romania SRL - Unit Tg. Jiu

55

0.7

0.04

1.37 Similar

International Healthcare Systems S.A - Dialysis center Craiova

75

0.79

0.1

1.47 Similar

CMDTAMP Bucharest

32

0.8

-0.19

1.8 Similar

130

0.8

0.3

1.29 Similar

Avitum SRL - Dialysis center Timisoara

72

0.81

0.17

1.45 Similar

Nefrocare Med Dialysis Center Medgidia

30

0.82

-0.21

1.84 Similar

Hemodialysis center
Fresenius NephroCare Pitesti - Dialysis center

NEFROCARE MS Dialysis Center - Iasi

Fresenius NephroCare Bacau - Dialysis center


SC Diaverum Romania SRL - Roman Unit
Fresenius NephroCare "Dr. Carol Davila - Dialysis center Bucharest

S.C. Nefromed Dialysis Centers SRL - Dialysis center Piatra Neamt


SC Diaverum Romania SRL- Dialysis center Sibiu
S.C. Renamed Dialcare SRL- Craiova

Fresenius NephroCare Brasov - Dialysis center

Signicance

71

Hemodialysis center

Prevalent
patients*
118

SMR

CI 95%

0.83

0.31

1.36 Similar

47

0.84

-0.03

1.7 Similar

127

0.84

0.34

1.34 Similar

33

0.86

-0.25

1.97 Similar

156

0.87

0.39

1.35 Similar

S.C. Clinica Medicala Arnaldo SRL Brasov

62

0.87

0.07

1.67 Similar

Renal Care Group - Dialysis center Giurgiu

59

0.87

0.07

1.67 Similar

S.C. RENAMED NEFRODIAMED SRL - Ramnicu Valcea

105

0.95

0.31

1.59 Similar

S.C. Nefroclinic SRL - Dialysis center Ploiesti

164

0.97

0.43

1.51 Similar

S.C. Renamed Medical Service II SRL- Dialysis center Turnu Severin

154

0.98

0.45

1.51 Similar

65

0.12

1.88 Similar

Fresenius NephroCare Constanta - Dialysis center

150

1.02

0.41

1.63 Similar

S.C. Nefromed Dialysis Centers SRL - Dialysis center Alba-Iulia

128

1.03

0.38

1.67 Similar

International Healthcare System S.A. - Dialysis center Focsani

131

1.08

0.42

1.74 Similar

Avitum SRL - Haemodialysis center Tg. Mures

118

1.13

0.39

1.87 Similar

75

1.18

0.23

2.12 Similar

S.C. Nefromed Hemodialysis Centers SRL - Dialysis center Cluj

162

1.19

0.53

1.84 Similar

S.C. Renamed Nefrodial SRL Oradea

146

1.24

0.54

1.94 Similar

75

1.26

0.21

2.3 Similar

132

1.34

0.5

2.17 Similar

International Healthcare Systems S.A - Dialysis center Calarasi

63

1.34

0.1

2.58 Similar

University Emergency Hospital Bucharest - Haemodialysis center SUUB

19

1.35

-0.83

3.53 Similar

Tulcea County Emergency Hospital - Dialysis center

17

1.45

-0.98

3.89 Similar

Avitum SRL - Dialysis center Targu-Jiu

119

1.48

0.54

2.43 Similar

Fresenius NephroCare Oradea - Dialysis center

175

1.52

0.74

2.31 Similar

Moinesti Dialysis station

27

1.53

-0.61

3.67 Similar

SC HIPARION MED SRL Targu Mures

28

1.53

-0.62

3.69 Similar

SC Diaverum Romania SRL - Unit Bucharest Industriilor


Constanta County Clinical Hospital - Haemodialysis center
Fresenius NephroCare Deva - Dialysis center
Avitum SRL - Dialysis center Sighisoara
S.C. Nefromed Dialysis Center SRL - Dialysis center Timisoara

Renal Care Group - Dialysis center Slobozia

S.C. VAMAGO SRL - Dialysis center Resita

Renal Care Group - Dialysis center Tulcea


SC Diaverum Romania SRL - Sibiu Unit

Signicance

72

Hemodialysis center
Baia Mare County Emergency Hospital - Haemodialysis center Baia Mare

Prevalent
patients*
45

SMR

CI 95%

Signicance

1.54

-0.14

3.22 Similar

S.C. NEFROMED SJ S.R.L. - Dialysis center Zalau

65

1.58

0.2

2.96 Similar

SC Diaverum Romania SRL - Bistrita Unit

61

1.59

0.11

3.07 Similar

SC Diaverum Romania SRL - Odorheiu Secuiesc Unit

45

1.6

-0.17

3.37 Similar

S.C. Nefromed Dialysis Centers SRL- Dialysis center Barlad

90

1.61

0.34

2.87 Similar

Floreasca Clinical Emergency Hospital Bucharest - Dialysis center

20

1.65

-0.74

4.04 Similar

Fresenius NephroCare Suceava - Dialysis center

120

1.66

0.58

2.75 Similar

Avitum SRL - Dialysis center Botosani

130

1.71

0.65

2.77 Similar

IHS "Sf. Ioan" Dialysis Center Bucharest

162

1.72

0.73

2.71 Similar

S.C. Nefromed Dialysis Centers SRL- Dialysis center Alexandria

101

1.73

0.49

2.97 Similar

S.C. Nefromed Dialysis Centers SRL - Dialysis center Baia Mare

80

1.75

0.31

3.19 Similar

Cluj-Napoca Town Clinical Hospital - Hemodialysis center

39

1.77

-0.3

3.84 Similar

Avitum SRL - Sf. Gheorghe Dialysis Center

47

1.79

-0.13

3.7 Similar

128

1.8

0.65

2.94 Similar

Prahova County Emergency Hospital - Haemodialysis center Ploiesti

90

1.8

0.43

3.17 Similar

"Sf. Ap. Andrei" Galati County Clinical Emergency Hospital - Dialysis center

15

1.84

-1.62

5.3 Similar

112

1.84

0.62

3.06 Similar

S.C. Renal Med SRL Bacau- Dialysis center Onesti

52

1.85

-0.01

3.71 Similar

Nefrocare CL Dialysis Center - Campulung

26

1.87

-1.02

4.75 Similar

S.C. Nefromed Dialysis Centers SRL - Dialysis center Botosani

80

1.89

0.35

3.43 Similar

S.C. Nefro Care Center - Dialysis center Bucuresti

56

1.89

0.09

3.7 Similar

Braila County Emergency Hospital - Dialysis center

27

1.91

-0.68

4.5 Similar

International Healthcare System S.A. - Dialysis center Petrosani

57

1.92

0.18

3.66 Similar

110

1.93

0.57

3.29 Similar

65

1.97

0.26

3.67 Similar

113

2.02

0.66

3.38 Similar

67

2.08

0.22

3.94 Similar

International Healthcare System S.A. - Dialysis center Buzau

S.C. Nefromed Dialysis Centers SRL - Dialysis center Satu Mare

Avitum SRL - Dialysis center Suceava


Craiova County Clinical Emergency Hospital - Dialysis center
SC Diaverum Romania SRL - Unit Bucharest - Splai Independentei
International Healthcare Systems S.A. - Dialysis center Galati

73

S.C. NEFROMED BM S.R.L. - Dialysis center Radauti

Prevalent
patients*
44

S.C. Diasys Medical SRL - Dialysis center Targoviste

Hemodialysis center

SMR

CI 95%

Signicance

2.09

-0.15

4.32 Similar

54

2.12

0.1

4.14 Similar

Dr Carol Davila Clinical Nephrology Hospital - Bucharest - Dialysis department

12

2.15

-2.21

6.51 Similar

International Healthcare Systems S.A - Dialysis center Fundeni

63

2.16

0.19

4.13 Similar

S.C. Eurodializa SRL Mangalia

26

2.2

-1

5.39 Similar

119

2.28

0.84

3.71 Similar

11

2.43

-2.81

7.67 Similar

2.49

-5.21

10.2 Similar

Bistrita Nasaud County Emergency Hospital - Haemodialysis center

16

2.54

-2.04

7.12 Similar

IHS Busteni Dialysis Center

11

2.58

-3.16

8.31 Similar

2.64

-5.76

11.04 Similar

S.C. MEDISS CENTER SRL - Targu Neamt

54

2.69

-0.04

5.41 Similar

Fagaras Town Hospital - Dialysis center

14

2.75

-2.41

7.92 Similar

2.75

-6.19

11.69 Similar

42

2.85

-0.29

5.99 Similar

2.86

-3.85

9.58 Similar

17

3.09

-2.23

8.41 Similar

3.17

-4.65

11 Similar

S.C. NEFROCARE DJ SRL - Dialysis center Dej

31

3.24

-0.8

7.28 Similar

SC Diaverum Romania SRL - Medias Unit

43

3.65

-0.47

7.76 Similar

3.72

-10.35

17.8 Similar

Timis County Hospital - Dialysis and renal transplantation center Timisoara

26

3.9

-1.44

9.24 Similar

County Emergency Hospital "Sf. Pantelimon" Vrancea - Dialysis center Focsani

10

3.96

-4.95

12.87 Similar

Drobeta Turnu-Severin Railway Hospital - Dialysis Center

17

4.06

-3.11

11.23 Similar

Lugoj Town Hospital - Dialysis station

14

4.24

-4.33

12.82 Similar

Arad County Clinical Emergency Hospital - Dialysis center

24

4.32

-1.19

10.55 Similar

Ploiesti General Railway Hospital - Dialysis station

13

4.51

-4.88

13.91 Similar

S.C. Hemo-Vest SRL Arad


Petrosani Emergency Hospital - "Wolfgan Steger Haemodialysis center
"Marie Curie" Children Emergency Hospital Bucharest

Satu Mare County Hospital - Dialysis center

"Sf. Maria" Clinical Children Emergency Hospital Iasi


Bacau County Emergency Hospital - Haemodialysis station
"Elena Beldiman Town Emergency Hospital - Dialysis center Barlad
Teleorman County Hospital - Dialysis center Alexandria
Sibiu County Clinical Emergency Hospital - Dialysis station

Caras Severin County Hospital - Resita

74

Hemodialysis center
Brasov County Clinical Emergency Hospital - Dialysis center

Prevalent
patients*
20

SMR

CI 95%

Signicance

5.11

-3.45

13.68 Similar

205

2.47

1.25

3.7 High

NE

NE

NE NE

11

NE

NE

NE NE

Fundeni Clinical Institute - Dialysis center

NE

NE

NE NE

Fundeni Clinical Institute - Pediatric department, Nephrology department and the Pediatric dialysis
department

NE

NE

NE NE

10

NE

NE

NE NE

Hunedoara Town Hospital - Haemodialysis center

NE

NE

NE NE

Ialomita County Emergency Hospital - Hemodialysis center Slobozia

NE

NE

NE NE

Mehedinti County Hospital - Dialysis center

NE

NE

NE NE

Neamt County Emergency Hospital - Dialysis center Piatra Neamt

NE

NE

NE NE

47

NE

NE

NE NE

"Sf. Ioan cel Nou" County Emergency Hospital Suceava - Dialysis center

NE

NE

NE NE

"Louis Turcanu" Pediatric Emergency Hospital - Pedriatrics I - Haemodialysis lab

NE

NE

NE NE

Sinaia Town Hospital - Dialysis department

NE

NE

NE NE

Oradea Railway Hospital

NE

NE

NE NE

Giurgiu County Hospital - Dialysis center

NE

NE

NE NE

"Sf. Ioan" Clinical Children Emergency Hospital Galati

NE

NE

NE NE

S.C. Specimed S.A.- Dialysis center Braila

39

NE

NE

NE NE

S.C. Gral Medical SRL- Dialysis center Bucharest

60

NE

NE

NE NE

Fundeni Clinical Institute - Renal transplantation department

15

NE

NE

NE NE

"Sf. Ioan" Clinical Emergency Hospital - Bucharest - Dialysis department

NE

NE

NE NE

International Healthcare System S.A. - Dialysis center Constanta

NE

NE

NE NE

26

NE

NE

NE NE

NE

NE

NE NE

8161

1.27

1.19

Fresenius NephroCare SRL - CI Parhon Clinical Hospital No. 2 Iasi


"Mavromati" County Hospital Botosani - Dialysis center
"N. Paulescu Institute for Nutrition and Metabolic Diseases - Dialysis center

Dambovita County Emergency Hospital - Hemodialysis center Targoviste

Arges County Hospital - Dialysis center Pitesti

DIA MEDICAL PORT - Bucharest


S.C. MALP srl Moinesti - Dialysis station
ROMANIA

1.36 High

* Prevalent haemodialysis patients on 31.12.2012


Low Standardized mortality ratio (SMR) strictly below 1 (indicates a mortality rate lower than that of the reference cohort); High SMR strictly above 1 (indicates a mortality rate higher than that of the
reference cohort); Similar SMR not dierent from 1 (indicates a mortality rate similar to that of the reference cohort); NA not assessed (too small number of patients or too small observation interval)

75

References
Cepoi V, Onofriescu M, Segall L, Covic A: The prevalence of chronic kidney disease in the general population in Romania: a study on 60,000 persons. Int Urol Nephrol
(2012) 44:213-220.
2
Cepoi V, Covic A, Volov C: Clinical epidemiologic assessment of the incidence of chronic kidney diseases registered in Romania, Iai County, in the years of 2004-2008.
Rev Med Chir Soc Med Nat Iasi (2009) 113:1070-6.
3
Covic A, Schiller A, Constantinescu O, Bredeean V, Mihescu A, Olariu N, Seica A, Cepoi V, Gusbeth-Tatomir P: Stage 3-5 chronic kidney disease - what is the real
prevalence in Romania? Rev Med Chir Soc Med Nat Iasi (2008) 112:922-31.
4
*** KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney int (2013) Suppl. 3:1-150.
5
Mircescu G, Stefan G, Grnea L, Mititiuc I, Siriopol D, Covic A: Outcomes of dialytic modalities in a large incident registry cohort from Eastern Europe: the Romanian
Renal Registry. Int Urol Nephrol (2014) 46:443-51.
6
U.S. Renal Data System, USRDS 2013 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health,
National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2014. Datele au fost furnizate de Statele Unite ale Americii Renal Data System (USRDS).
Interpretarea i modul de raportare a acestora sunt responsabilitatea autorilor i nu trebuie privite drept politic ocial sau interpretare a Guvernului SUA.
7
ERA-EDTA Registry: ERA-EDTA Registry Annual Report 2012. Academic Medical Center, Department of Medical Informatics, Amsterdam, Olanda.
8
Noordzij M, Kramer A, Abad Diez JM et al: ERA-EDTA Registry: Renal replacement therapy in Europe: a summary of the 2011 ERAEDTA Registry Annual Report. Clin
Kidney J (2014) 7: 227238.
9
Wolfe RA, Gaylin DS, Port FK, PJ Held, Wood CL: Using USRDS generated mortality tables to compare local ESRD mortality rates to national rates.Kidney Int (1992)
42:991996
1

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