REGISTRY OF THE NEPHROLOGY, DIALYSIS AND TRANSPLANTATION IN TURKEY

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PUBLISHED BY THE TURKISH SOCIETY OF NEPHROLOGY

REGISTRY OF THE NEPHROLOGY, DIALYSIS

AND

TRANSPLANTATION IN TURKEY

REGISTRY 2004

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PUBLISHED BY THE TURKISH SOCIETY OF NEPHROLOGY

Important Note

All copyrights are reserved for Turkish Society of Nephrology.

Articles and figures might not be published without reference.

Contents and Design: OMEGA Contract Research Organization Printing: Art Ofset

Printing date: June 2005

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INTRODUCTION

15 Years in Turkish Nephrology Registry

Nephrology, Dialysis and Transplantation studies which are started in 1989 including solely Istanbul, are being performed in country wide since 1990 and published by Turkish Society of Nephrology, annually

(except 1994). On the following two pages, you might see the names of the books and people who have worked throughout the publishing process.

Till 1993 a lot of friends of us have taken place in Central Registry Committee. I am grateful to them.

For efforts they spent in communicating with foreign and domestic nephrology centers and for supports in evaluating and commenting the collected data, I especially thankful to Kamil Serdengeçti, President of Turkish Society of Nephrology and to Gültekin Süleymanlar, General Secretary, who are the indispensable and permanent names of our society.

Mehmet Rıza Altıparmak and Nurhan Seyahi, two young assistant members of Central Registry Committee have spent too much effort. Many thanks to them and to Lale Sever who has given her best support in evaluation of pediatric nephrology results.

Registry studies which were performed with an amateur spirit till three years ago, are being executed by a professional company since 2002, under control, support and audition of our Central Registry Committee.

You might see the graphics showing the now and then of the Turkish Registry for a period of 15 years.

In recent years, Turkish Nephrology Registry has started to take place in two big registries as a result of contribution established with ERA-EDTA and USRDS.

For the support they gave to Turkish Nephrology Registry, we are grateful to Kitty Jager, Director of the ERA- EDTA Nephrology Center and to Allan J. Collins, Director of the USRDS Coordinating Center. You might also find the figures of this two big registries and comparative graphics by USRDS, including Turkish results.

Turkish Registry of 2004 is completed again with the extreme supports of the responsible persons of

nephrology, dialysis and transplantation centers. We stated the names of both them and the centers at the back pages of this book. By this means we voice our gratitudes to them.

We are also grateful to managers and the staff of Omega Contract Research Organization who have collected the data under the control and support of our Central Registry Committee and prepared the analysis report, and to Fresenius Medical Care, the company that has yet once more sponsored the printing of this book.

June 2005, Cerrahpaşa, Istanbul

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TURKISH SOCIETY OF NEPHROLOGY REGISTRY GENERAL COMMITTEE

General Coordinator: Prof. Dr. Kamil SERDENGEÇTİ

President of Turkish Society of Nephrology EDTA-ERA Registry Coordinator for Turkey Assistant Coordinator: Prof. Dr. Gültekin SÜLEYMANLAR

General Secretary of Turkish Society of Nephrology Assistant Members to Central Registry Committee:

Assoc. Prof. Mehmet Rıza ALTIPARMAK, Dr. Nurhan SEYAHİ Coordinator for Pediatric Nephrology:

Prof. Dr. Lale SEVER

Regional Coordinators for Ankara and Mid-Turkey:

Şali ÇAĞLAR, Mehmet HABERAL, Enver HASANOĞLU, Şükrü SİNDEL, Neval DUMAN, Ayşın BAKKALOĞLU, Oğuz SÖYLEMEZOĞLU, Ayşe ÖNER, Haluk KİPER, Cengiz UTAŞ, Süleyman TÜRK, Necmettin GÜVENCE

Regional Coordinators for Istanbul and Thrace Region:

Emel AKOĞLU, Mehmet SEVER, Rezzan ATAMAN, Mine BESLER, Funda TÜRKMEN, Uluğ ELDEGEZ, Muzaffer SARIYAR, Saniye ŞEN, Metin ERMAN, Nedim SARSMAZ Hülya Karadayı ERGİN

Regional Coordinators for Bursa and Marmara Region:

Mustafa YURTKURAN, Kamil DİLEK, Mustafa GÜLLÜLÜ, Nilay OKTAY, Betül KALENDER Regional Coordinators for Izmir and Aegean Region:

Ali BAŞÇI, Sevgi MİR, Taner ÇAMSARI, Fehmi AKÇİÇEK Cüneyt HOŞCOŞKUN, Adam USLU

Regional Coordinators for Black Sea Region:

Tekin AKPOLAT, Nurol ARIK, Şükrü ULUSOY Regional Coordinators for Eastern Turkey:

Yılmaz SELÇUK, Reha ERKOÇ

Regional Coordinators for Southeastern Turkey:

Bünyamin IŞIKOĞLU, Emin YILMAZ, Asım GÖYMEN Regional Coordinators for Adana and Çukurova Region:

Yahya SAĞLIKER, Uğur EKREN, Zeki GÜLOĞLU, Saime PAYDAŞ Regional Coordinators for Antalya and Mediterranean Region:

Gülşen YAKUPOĞLU, Fevzi ERSOY, Alper DEMİRBAŞ Communication and Assistance in Data Collection:

Executive Secretary: Mübeccel AKYÜZ

Central Registry Committee Secretary: Şükran AKPINAR Project Management:

Omega Contract Research Organization Project Managers:

Ebru MUTLU, Hakan YILMAZ Assistant Project Manager

Kartal ÇETİNTÜRK Regional Project Managers:

Öznur BİÇEROĞLU, Yeşim KOÇ (Ankara), Güliz ÖZGEN (İstanbul), Buket ÜNAK (İzmir), Mesut BAHAR (Samsun)

Data Analysis and Reporting:

Oktay ÖZDEMİR, Ferit ÜN, Bülent SAKAOĞLU Database Management and Software Development:

Berk ÖZDEMİR, Taner SUNDU, Taner VAROL Data Entry Officers:

Fatih ELİTOĞ, Emre ÖZKAN Review of Forms:

Hakan YILMAZ, Kartal ÇETİNTÜRK, Serpil ÇOBAN Graphics and Translation:

Murat KİRTİŞ

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The Registry Books Published in Last 15 Years

1. Today of Hemodialysis in Istanbul, Istanbul 1989

Publishing Committee: Ekrem Erek, Serhat Perk. Publisher: Turkish Society of Nephrology, number of pages: 48

2. Today of Nephrology, Dialysis and Transplantation in Turkey, 1990

Publishing Committee: Ekrem Erek, Serhan Dalmak. Publisher: Turkish Society of Nephrology, number of pages: 97.

3. Nephrology, Dialysis and Transplantation in Turkey, Registry 1991

Publishing Committee: Ekrem Erek, Rezzan Ataman, Serran Dalmak, Süheyla Apaydın.

Publisher: Turkish Society of Nephrology, number of pages: 49.

4. Nephrology, Dialysis and Transplantation in Turkey, Registry 1992-1993

Publishing Committee: Ekrem Erek, Kamil Serdengeçti, Rezzan Ataman, Süheyla Apaydın.

Publishing Committee: Ekrem Erek, Gültekin Süleymanlar, Kamil Serdengeçti.

9. Nephrology, Dialysis and Transplantation in Turkey, Registry 1999 (including English version) Central Registry Committee: Ekrem Erek, Gültekin Süleymanlar, Kamil Serdengeçti.

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DEMOGRAPHICS OF TURKEY

Background : Modern Turkey was founded in 1923 by Kemal ATATÜRK after a war of independence, following the fall of the 620-years-old Ottoman Empire. Under his leadership, the country adopted wide-ranging social, legal, and political reforms.

Location : Southeastern Europe and southwestern Asia

Area : Total: 780.580 sq km

Population : 73.330.000

Age structure : 0-14 years: 26% (male 9.232.439/female 8.897.135) 15-64 years: 67.3% (male 23.806.367/female 23.053.536) 65 years and over: 6.7% (male 2.140.242/female 2.530.840) (2005 est.)

Median age : Total: 27.7 years

Population growth rate : 1.8% (2005 est.)

Life expectancy at birth : Total population: 72.36 years Male: 69.94 years

Female: 74.91 years (2005 est.) Total fertility rate : 1.94 children born/woman (2005 est.) Number of medical faculties : 35 state, 6 private (January 2001) Number of physicians : 95.192 (2002)

specialists : 43.662

general practitioners : 51.530

Number of nurses : 70.270 (4020 private) Per capita income : 4250 $/year (2004)

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ABBREVIATIONS

APD ... Automated peritoneal dialysis BP ... Blood pressure

CAPD ... Continuous ambulatory peritoneal dialysis CGN ... Chronic glomerulonephritis

CRF ... Chronic renal failure DM... Diabetes mellitus EPO ... Erythropoietin

ESRD ... End stage renal disease GFR ... Glomerular filtration rate HD ... Hemodialysis

HT ... Hypertension

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2004 REGISTRY

Number of centers invited to Registry (including pediatric nephrology centers) ... 459

Number of centers that do not fit Registry inclusion criteria ... 9

Number of centers without HD unit... 3

Number of centers where HD units were closed in 2004... 5

Number of centers that could not be reached ... 1

Number of centers that fit Registry inclusion criteria ... 450

Number of non-responding centers ... 10

Number of responding centers and response rate... 440 (97.8%) Number of centers per million population ... 6.2

HD centers

Number of specialist physicians ... 439

Number of general practitioners ... 699

Total number of physicians ... 1138

Number of nurses ... 2827

Number of HD equipments... 5964

PD centers

Number of specialist physicians ... 85

Number of general practitioners ... 38

Total number of physicians ... 123

Number of nurses ... 124

Pediatric nephrology centers

Number of centers invited to Registry ... 32

Number of responding centers and response rate... 32 (100%) Number of centers with HD units ... 23

Number of centers with PD units ... 30

Number of centers where RTx is performed ... 15

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CLINICAL NEPHROLOGY

Incident ESRD* patients in 2004

Pre-dialysis patients... 30.8%

HD patients ... 58.9%

PD patients ... 8.0%

Tx patients ... 2.3%

Prevalent ESRD patients, as of the end of 2004

Pre-dialysis patients... 25.5%

HD patients ... 58.4%

PD patients ... 10.0%

Tx patients ... 6.1%

Primary renal diseases in incident ESRD patients in 2004

Diabetes mellitus ... 25.3%

Hypertensive renal disease ... 17.2%

Chronic glomerulonephritis ... 13.4%

Other diseases ... 20.5%

Etiology unknown ... 23.6%

Primary renal diseases in prevalent ESRD patients, as of the end of 2004

Diabetes mellitus ... 23.1%

Hypertensive renal disease ... 19.8%

Chronic glomerulonephritis ... 16.3%

* GFR less than 15 mL/min for non-diabetic patients and GFR less than 20 mL/min for diabetic patients are accepted as ESRD.

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Response rate by years

77.5

94.1 96.2 94.4 97.6

60 70 80 90 100

2000 2001 2002 2003 2004

Percent

Treatment modalities in incident RRT patients (2004)

84.1

11.6 3.3

0 20 40 60 80 100

HD PD Tx

% of pts.

Treatment modalities in prevalent RRT patients (2004)

78.4

13.4 8.2

0 20 40 60 80 100

HD PD Tx

% of pts.

(13)

Etiology of incident ESRD patients (2004)

23.6 6.8

3.9 4.0

5.8

13.4 17.2

25.3

0 10 20 30

Etiology unknown Miscellaneous Cystic renal disease Chronic interstitial nephritis Urologic disease Chronic glomerulonephritis Hypertensive renal disease Diabetes mellitus

% of pts.

Etiology of prevalent ESRD patients (2004)

5.3 5.7

16.3 19.8

23.1

Cystic renal disease Urologic disease Chronic glomerulonephritis Hypertensive renal disease Diabetes mellitus

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TRENDS IN CLINICAL NEPHROLOGY BY YEARS

RRT patients with diabetic nephropathy by years

4.5 4.6

15.3 16.9 13.6

18.1 16.4 15.8 25.3

22.8 25.3

0 10 20 30

1991 1993 1995 1996 1997 1998 1999 2000 2001 2003 2004

% of pts.

RRT patients with cystic renal disease by years

2.5

6.6 4.1

6.0

4.5 4.2 5.8

2.8

3.9

0 5 10 15

1991 1996 1997 1998 1999 2000 2001 2003 2004

% of pts.

Discussion

 Evaluation is performed based on the results provided by 440 centers (number of pediatric nephrology centers: 32).

 In the year 2004, the point prevalence and incidence rates of ESRD treated with RRT are found as 444 pmp and 123 pmp, respectively. There is an increase in both point prevalence and incidence rates as compared to last year.

 First three etiologic diseases causing chronic renal disease among incident ESRD patients in 2004 are found as diabetes mellitus (25.3%), hypertension (17.2%) and chronic glomerulonephritis (13.4%), respectively.

 First three etiologic diseases causing chronic renal disease among prevalent ESRD patients as of the end of 2004 are found as diabetes mellitus (23.1%), hypertension (19.8%) and chronic glomerulonephritis (16.3%), respectively.

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RENAL REPLACEMENT THERAPIES

HEMODIALYSIS

Incident regular HD patients in 2004

Male ... 54.9%

Female ... 45.1%

0-15 years of age ... 0.4%

16-19 years of age ... 1.3%

20-44 years of age ... 21.7%

45-64 years of age ... 48.9%

65-74 years of age ... 20.8%

75+ years of age ... 6.8%

Prevalent regular HD patients as of the end of 2004 ... 25.321 Male ... 56.2%

Female ... 43.8%

0-15 years of age ... 0.3%

16-19 years of age ... 1.4%

20-44 years of age ... 28.8%

45-64 years of age ... 42.9%

65-74 years of age ... 20.7%

Frequency of HD sessions in regular HD patients, as of the end of 2004

Once weekly ... 1.6%

Twice weekly ... 13.6%

Three times weekly ... 84.8%

Duration of dialysis in regular HD patients, as of the end of 2004

0-5 years ... 69.6%

6-10 years ... 22.4%

11-15 years ... 6.2%

16-20 years ... 1.5%

20+ years ... 0.2%

Number of dialysers consumed in 2004 ... 3.234.687 Synthetic ... 54.0%

Semi-synthetic ... 35.8%

High-flux ... 8.9%

Cuprophane... 1.3%

Percentage of regular HD patients with urea reduction rate higher than 0.65,

as of the end of 2004 ... 68.1%

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AV fistula localization in regular HD patients, as of the end of 2004

Forearm 1/3 distal region ... 42.0%

Forearm 1/3 mid-region ... 25.0%

Arm 1/3 distal ... 23.7%

Snuff-box ... 8.5%

Femoral ... 0.8%

Anticoagulation method in regular HD patients, as of the end of 2004

Standard heparinization ... 56.5%

Low-molecular weight heparinization ... 42.5%

Regional heparinization ... 0.1%

Miscellaneous ... 0.9%

Hypertension in regular HD patients, as of the end of 2004

Hypertensive ... 40.7%

BP >140/90 mmHg, on antihypertensive treatment ... 13.5%

BP >140/90 mmHg, not on antihypertensive treatment ... 6.9%

BP <140/90 mmHg, on antihypertensive treatment ... 20.3%

Normotensive (BP <140/90 mmHg, not on antihypertensive treatment) ... 59.3%

Cardiovascular diseases in regular HD patients, as of the end of 2004

Left ventricular hypertrophy... 19.3%

Coronary heart disease... 9.5%

Heart failure ... 6.8%

Arrythmia ... 5.5%

Percentage of regular HD patients with hypoalbuminemia (less than 3.5 g/dL),

as of the end of 2004 ... 12.9%

Erythropoietin treatment in regular HD patients, as of the end of 2004

Percentage of HD patients on erythropoietin treatment ... 62.8%

Percentage of HD patients with erythropoietin resistance ... 7.7%

Iron treatment in regular HD patients, as of the end of 2004

HD patients on iron treatment ... 58.9%

Oral iron treatment ... 5.0%

Parenteral iron treatment ... 53.9%

Serum intact PTH levels (pg/mL) in regular HD patients, as of the end of 2004

<100 ... 26.7%

100-300 ... 36.6%

300-500 ... 17.7%

500-1000 ... 11.7%

>1000 ... 6.1%

Phosphate-binding treatment in regular HD patients, as of the end of 2004

HD patients on phosphate-binding treatment ... 87.3%

Calcium acetate ... 66.7%

Calcium carbonate ... 13.3%

Aluminium hydroxide ... 4.7%

Sevelamer ... 2.0%

Active vitamin D treatment in regular HD patients, as of the end of 2004

HD patients on vitamin D treatment ... 41.3%

Oral vitamin D treatment ... 14.3%

IV vitamin D treatment ... 27.0%

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Hepatitis serology in regular HD patients, as of the end of 2004

HBsAg (+)... 4.9%

Anti-HCV Ab (+) ... 19.3%

Both HBsAg and Anti-HCV Ab (+) ... 1.5%

Deaths in regular HD patients, in 2004

Deaths due to any cause ... 3.441 (14.4%) within the first 90 days of dialysis ... 4.5%

after 90 days of dialysis ... 9.9%

Causes of death

Deaths due to cardiovascular causes ... 46.7%

Deaths due to cerebrovascular accidents ... 12.6%

Deaths due to malignancies... 10.4%

Deaths due to infections ... 9.7%

Deaths due to other causes ... 20.4%

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Age distribution of incident regular HD patients (2004)

0.4 1.3

21.7

48.9

20.8

6.8 0

20 40 60 80

0-15 16-19 20-44 45-64 65-74 75+

Years of age

% of pts.

Mean age of incident regular HD patients (2004)

53.2 54.4 53.8

0 20 40 60

Male Female Total

Years of age

Age distribution of incident regular HD patients with diabetic nephropathy (2004)

0.3 0.3

11.9

51.8

29.0

6.7 0

20 40 60

0-15 16-19 20-44 45-64 65-74 75+

Years of age

% of pts.

(19)

Age distribution of prevalent regular HD patients (2004)

0.3 1.4

28.8

42.9

20.7

5.8 0

20 40 60

0-15 16-19 20-44 45-64 65-74 75+

Years of age

% of pts.

Age distribution of prevalent regular HD patients with diabetic nephropathy (2004)

0.0 0.2

13.0

52.3

28.6

6.0 0

20 40 60

0-15 16-19 20-44 45-64 65-74 75+

Years of age

% of pts.

Frequency of HD sessions in regular HD patients (2004) 84.8

60 90

of pts.

(20)

Distribution of dialyser membranes in regular HD patients (2004)

54.0

35.8

8.9

1.3 0

20 40 60

Synthetic Semisynthetic High-flux Cuprophane

% of pts.

Urea Reduction Rate (URR) in regular HD patients (2004)

31.9

68.1

0 20 40 60 80

≤0.65 >0.65

% of pts.

Urea kinetics model usage in HD centers (2004)

37.8

62.2

0 20 40 60 80

Yes No

% of centers

(21)

Kt/V ratios in regular HD patients (2004)

2.0 7.9 25.2 60.2 4.7

3.6 12.8 28.7 47.1 7.9

0 20 40 60 80

≤0.80 0.81-1.00 1.01-1.20 1.21-1.80 >1.80

% of pts.

3/week 2/week

Types of vascular access in regular HD patients (2004) 90.1

3.5 2.6 3.7

0 20 40 60 80 100

AV fistula (native)

Persistent (tunnel) catheter

AV graft (prosthesis)

Misc.

% of pts.

AV fistula localization in regular HD patients (2004)

26.6 29.3 29.3 38.7 29.3

73.4 70.7 70.7 61.3 70.7

20 40 60 80 100

% of pts.

Right Left

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AV fistula localization in regular HD patients (2004)

42.0

25.0 23.7

8.5

0.8 0

20 40 60

Forearm 1/3 distal region

Forearm 1/3 mid region

Arm 1/3 distal region

Snuff-box Femoral region

% of pts.

Anticoagulation methods used in regular HD patients (2004) 56.5

42.5

0.1 0.9

0 20 40 60

Standard heparinization

Low molecular weight heparinization

Regional heparinization

Misc.

% of pts.

Blood pressure status in regular HD patients (2004)

59.3

20.3

6.9 13.5

0 20 40 60 80

BP <140/90 mmHg untreated

BP <140/90 mmHg treated

BP >140/90 mmHg untreated

BP >140/90 mmHg treated

% of pts.

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Cardiovascular diseases in regular HD patients (2004)

0.5 0.7

1.1 1.1 1.2 1.7

2.9 5.5 5.5

6.8

19.3

0 5 10 15 20

Infective endocarditis Pericarditis Coronary angioplasty / stent Cerebrovascular accident Acute myocardial infarction Coronary by-pass surgery Peripheral arterial disease Angina pectoris Arrythmia Heart failure Left ventricle hypertrophy

% of pts.

Serum albumin levels in regular HD patients (2004)

12.9

87.1

0 30 60 90

<3.5 g/dL >3.5 g/dL

% of pts.

(24)

Erythropoietin usage in regular HD patients (2004)

62.8

37.2

0 20 40 60 80

Yes No

% of pts.

Regular serum ferritin measurement in HD centers (2004) 79.5

20.5

0 20 40 60 80

Yes No

% of centers

Iron treatment in regular HD patients (2004)

5.0

53.9

41.1

0 20 40 60

Oral Parenteral None

% of pts.

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Renal bone disease tests performed in HD centers (2004)

3.7 4.2 6.0

8.2 13.4

21.6 27.5

70.2 74.7

97.5

0 20 40 60 80 100

Serum osteocalcin Bone biopsy Deferoxamine test Serum Vit-D metabolites Serum aluminium Bone-specific alkaline phosphatase Parathyroid scintigraphy Serum intact parathormone Bone X-rays Routine biochemical tests

% of centers

Serum intact parathormone levels in regular HD patients (2004)

26.7

36.6

17.7

11.7

6.1 0

20 40

<100 100-300 300-500 500-1000 >1000 pg/mL

% of pts.

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Phosphorus binding agents used in regular HD patients (2004)

12.7 0.7

2.0 4.7

13.3

66.7

0 20 40 60 80

None Misc.

Sevelamer Aluminium hydroxide Calcium carbonate Calcium acetate

% of pts.

Active vitamin D used in regular HD patients (2004)

14.3

27.0

58.7

0 20 40 60

Oral IV None

% of pts.

(27)

Hepatitis serology in regular HD patients (2004)

4.9

19.3

1.5 0

10 20

HBsAg (+) Anti-HCV (+) HBsAg (+) and Anti-HCV (+)

% of pts.

Duration of dialysis in regular HD patients (2004) 69.6

22.4

6.2 1.5 0.2

0 20 40 60 80

≤5 6-10 11-15 16-20 >20

Years

% of pts.

(28)

Causes of death in regular HD patients (2004)

17.3 1.2

1.9

9.7 10.4

12.6

46.7

0 10 20 30 40 50

Misc.

Pulmonary emboli Hepatic failure Infection Malignancy Cerebrovascular

accident Cardiovascular

% of total deaths

Deaths due to cardiovascular diseases in regular HD patients (2004)

45.6 44.3

7.2 2.5

0 20 40 60

Heart failure Ischemic heart disease

Arrythmia Misc.

% of cardiovascular deaths

Discussion

 Evaluation is performed based on the results provided by 395 hemodialysis (HD) centers. The number of the centers contributed (n: 388), the number of HD equipments (n: 5964), and the number of HD patients (n: 25321) are increased by 13.0% compared to last year. The proportion of patients who are 15 years old or younger is 0.3%. With a percentage of 79.0%, HD is the most commonly used RRT method in Turkey. The total number of physicians and nurses are 1138 and 2829, respectively. There are some differences in numbers as compared to the numbers from Ministry of Health. There are several reasons of this: unlike the report of Ministry of Health, this report does not include;

o the incident HD patients of 2005, o the numbers of died HD patients,

o the potential HD patients of the centers newly established their HD equipments.

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 The proportion of diabetic patients among the HD patients is increased from 19.2% to %23.0 and this fact shows that diabetes mellitus, as a cause of ESRD, has an increasing rate in Turkey as well.

 The age range of HD patients: 49.8% of all patients and 52.4% of diabetic patients are in the age range of 45 and 64.

 Frequency of HD sessions: three times weekly for 84.8%, twice weekly for 13.6%, and once weekly for 1.6%. There is an increase in the frequency of 3 sessions/week compared to last year.

 A total of 3.235.000 dialysers are used in 385 centers in the year 2004. Decrease in cuprophane usage (1.3%) continues while there is a significant increase in synthetic membrane usage.

Synthetic membranes are the most commonly prescribed membranes (54%) in the year 2004.

High-flux membrane usage is 8.9%.

 There is an increase in urea kinetics model usage in the evaluation of dialysis sufficiency; it is used by 62.2% of the centers. Urea Reduction Rate is lower than 0.65 in 68.1% of chronic HD patients. Kt/V is higher than 1.2 in 63.7% of the patients.

 AV fistula is the vascular access route in 90.1% of HD patients and is opened on left arm with a proportion of over 70%. In 57.1% of the patients, dialysis is continued with the initial AV fistula. In 42.5% of the HD patients, low molecular weight heparine is used for anticoagulation.

 The frequency of hypertension in HD patients is found as 40.7%.

 Serum albumin level which is one of the reliable indicators of nutrition is lower than 3.5 g/dL in 12.9% of the HD patients. Results are better as compared to last year. The proportion of the patients whose serum albumin level is higher than 4.0 g/dL is 33.6%.

 The frequency of EPO usage in HD patients is 62.8% and there is a decrease when compared to last year. Target HB level (>11 g/dL) is reached in only 58.3% of the patients receiving EPO. EPO resistance is found in 7.7% of HD patients. This figure shows decrease as compared to last year (10.6%). Iron treatment is administered in 58.9% of HD patients (oral: 5.0%, parenteral: 53.9%).

Routine serum ferritin tests are performed in 79.5% of the centers.

 Routine biochemical tests (97.5%), bone X-rays (74.7%), and parathyroid scintigraphy (70.2%) are the most commonly used tests for renal bone disease in HD patients. The proportions of patients with iPTH level <100 pg/mL and >1000 pg/mL are 26.7% and 6.1%, respectively. Calcium acetate (66.7%), calcium carbonate (13.3%), and sevelamer (2.0%) are used as phosphorus binding agents in HD patients. There is a decrease in the rates of oral (14.3%) and IV (27%) active vitamin D usage compared to last year. Parathyroidectomy is performed in 226 patients. Venous

bicarbonate level test is practiced in only 6.6% of the centers, for acidose follow up.

 There found no change in the frequency of HBV infection in HD patients compared to last year.

The frequency of anti-HCV (+) patients continues to decrease (from 24.6% to 19.3%).

 Dialysis duration is longer than 6 years in more than 30% of HD patients. 31.0% of the HD patients died within the first 3 months, which is same as last year. With a rate of 46.7%, cardiovascular diseases are the most common cause of death in HD patients. Cerebrovascular

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TRENDS IN REGULAR HEMODIALYSIS THERAPY BY YEARS

Number of regular HD patients by years

3069 3494 5400 6527 7014 9658 11339 12196 14086 18815 20600 23387 25321

0 5000 10000 15000 20000 25000 30000

1990 1991 1993 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Count

Frequency of HD sesions in regular HD patients by years

0 20 40 60 80 100

1991 1993 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

% of pts.

1/week 2/week 3/week

Types of dialysate used in regular HD patients by years

0 20 40 60 80 100

1995 1997 1998 1999 2000 2001 2002

% of pts.

Bicarbonate Acetate

(31)

Types of vascular access in regular HD patients by years

83.0 88.4 87.5 90.1

14.1 9.1 3.5 3.5

2.9 2.5 3.5 2.65.5 3.8

0 20 40 60 80 100

1998 1999 2003 2004

% of pts.

AV fistula Catheter Graft Other

Hypoalbuminemia (<3.5 g/dL) in regular HD patients by years

34.5

19.8 23.0

18.3 16.2 14.7 17.3 19.2

15.4 12.9

0 10 20 30 40

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

% of pts.

Erythropoietin usage in regular HD patients by years 80

(32)

Erythropoietin resistance in regular HD patients by years

10.6 9.5

7.7

0 3 6 9 12

2002 2003 2004

% of pts.

Iron treatment in regular HD patients by years

73.5

60.4 58.9

0 20 40 60 80

1995 2003 2004

% of pts.

Active vitamin D usage in regular HD patients by years

85.0

73.6

62.2

70.6

50.5 45.2

40.4 41.3

0 30 60 90

1995 1998 1999 2000 2001 2002 2003 2004

% of pts.

(33)

Frequency of HBsAg (+) regular HD patients by years 15.0

10.0 8.1

12.7

11.1 10.5

7.5 7.9 7.6

6.5 5.9 6.4

0 5 10 15

1991 1993 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

% of pts.

Frequency of Anti-HCV (+) regular HD patients by years

54.6

41.7

36.2

29.6 28.8

26.3 23.2

20.8

0 20 40 60

1997 1998 1999 2000 2001 2002 2003 2004

% of pts.

Deaths due to cardiovascular disease in regular HD patients by years

(34)

Deaths due to cerebrovascular accident in regular HD patients by years

10.6 11.2 12.9 15.0

13.4 12.6 12.6 13.1

0 5 10 15 20

1995 1996 1997 1998 1999 2002 2003 2004

Deaths due to infections in regular HD patients by years

11.6

9.3 10.0

8.0

10.4 9.9 11.6 9.7 7.8

0 5 10 15

1996 1997 1998 1999 2000 2001 2002 2003 2004

Deaths due to malignancies in regular HD patients by years

6.0 6.5

9.1 8.9

9.1 10.4

0 3 6 9 12

1998 1999 2001 2002 2003 2004

(35)

Deaths due to hepatic failure in regular HD patients by years

2.8 3.0

4.8

3.5 3.1

2.4 1.9 2.8

0 2 4 6 8 10

1996 1997 1998 1999 2001 2002 2003 2004

Discussion

 The proportion of regular HD patients is increased by 15-20% in the last 15 years.

 The increase in the weekly HD sessions is more significant for 3 sessions/week.

 Hygienic conditions have provided the significant decrease in the percentage of HBsAg (+) regular HD patients through years. The decrease in the proportion of anti-HCV (+) patients can be

prevented by hygienic conditions, too.

 Acetate usage as a dialysate has almost left its place to bicarbonate.

 In Turkey, the most commonly preferred vascular access route is native AV fistula. Unlike USA the proportion of graft is too small.

 The percentage of EPO usage has showed no significant change through years, while there is an decrease in vitamin D usage, which is a result of . This decrease is a result of strict follow-up of patients.

 Hypolbuminemia is decreased to 12.9% in 2004. This result is very satisfactory as a matter of nutrition.

 Decrease in iron treatment is observed through 15 years.

 Through 15 years there observed no significant change in the percentage of deaths due to cardiovascular, cerebrovascular accident or infection.

 There is a slight increase in the proportion of deaths due to malignancy.

 Preventing the factors causing resistance, the frequency of EPO resistance is decreased.

(36)

(37)

PERITONEAL DIALYSIS

Incident CAPD patients in 2004 ... 1.230 Male ... 52.1%

Female ... 47.9%

0-15 years of age ... 1.9%

16-19 years of age ... 2.1%

20-44 years of age ... 34.1%

45-64 years of age ... 42.4%

65-74 years of age ... 15.9%

Incident APD patients in 2004 ... 271 Male ... 57.6%

Female ... 42.4%

0-15 years of age ... 1.5%

16-19 years of age ... 1.8%

20-44 years of age ... 46.1%

45-64 years of age ... 38.0%

65-74 years of age ... 10.3%

Prevalent PD patients as of the end of 2004 ... 3.320 Duration of dialysis in PD patients, as of the end of 2004

0-5 years ... 87.8%

6-10 years ... 11.7%

11-15 years ... 0.5%

Hypertension in PD patients, as of the end of 2004

Normotensive (BP < 140/90 mmHg, not on antihypertensive treatment) ... 38.7%

Cardiovascular diseases in PD patients, as of the end of 2004

Arrythmia ... 3.1%

Percentage of PD patients with hypoalbuminemia (less than 3.5 g/dL),

as of the end of 2004 ... 28.9%

(38)

Serum intact PTH levels (pg/mL) in PD patients, as of the end of 2004

<100 ... 25.8%

100-300 ... 33.0%

300-500 ... 22.2%

500-1000 ... 11.8%

> 1000 ... 7.2%

Phosphate-binding treatment in PD patients, as of the end of 2004

PD patients on phosphate-binding treatment ... 86.2%

Calcium acetate ... 56.4%

Calcium carbonate ... 20.0%

Aluminium hydroxide ... 6.1%

Sevelamer ... 2.5%

Active vitamin D treatment in PD patients, as of the end of 2004

PD patients on vitamin D treatment ... 40.2%

Oral vitamin D treatment ... 37.8%

IV vitamin D treatment ... 2.4%

Hepatitis serology in PD patients, as of the end of 2004

HBsAg (+)... 4.8%

Anti-HCV Ab (+) ... 8.9%

Complications in PD patients, in 2004

Percentage of PD patients who experienced peritonitis ... 29.3%

Rate of peritonitis ... 1/29.7 months Other complications

Hyperlipidemia ... 23.4%

Obesity ... 8.4%

Hernia ... 7.2%

Psychological problems ... 6.0%

Insufficient dialysis ... 5.6%

Hyperglycemia ... 3.1%

Causes of deaths in PD patients, in 2004

Deaths due to cardiovascular causes ... 37.1%

Deaths due to infections ... 17.3%

Deaths due to cerebrovascular accident ... 8.2%

Deaths due to malignancies ... 3.3%

Deaths due to other causes ... 34.0%

(39)

Age distribution of incident CAPD patients (2004)

1.9 2.1

34.1

42.4

15.9

3.7 0

10 20 30 40 50

0-15 16-19 20-44 45-64 65-74 75+

Years of age

% of pts.

Age distribution of incident APD patients (2004)

1.5 1.8

46.1

38.0

10.3

2.2 0

10 20 30 40 50

0-15 16-19 20-44 45-64 65-74 75+

Years of age

% of pts.

Mean age of incident PD patients (2004)

48.7 48.2 48.5

40 60

of age

(40)

Age distribution of incident PD patients with diabetic nephropathy (2004)

0.0 0.6

18.0

54.4

22.3

4.6 0

20 40 60

0-15 16-19 20-44 45-64 65-74 75+

Years of age

% of pts.

Blood pressure status in PD patients (2004)

38.7

28.6

6.3

26.4

0 20 40

% of pts.

(41)

Cardiovascular diseases in PD patients (2004)

0.5 0.5 0.7 0.7 0.8 0.8

2.1 2.3

3.1 3.8

12.8

0 5 10 15

Pericarditis Acute myocardial infarction Infective endocarditis Coronary by-pass surgery Coronary angioplasty / stent Cerebrovascular accident Angina pectoris Peripheral arterial disease Arrythmia Heart failure Left ventricle hypertrophy

% of pts.

Serum albumin levels in PD patients (2004)

28.9

71.1

0 20 40 60 80

<3.5 g/dL >3.5 g/dL

% of pts.

(42)

Complications other than peritonitis in PD patients (2004)

3.1 4.4

5.6 6.0

7.2 8.4

23.4

0 10 20 30

Hyperglycemia Drainage dysfunction Insufficient dialysis Psychological

problems Hernia Obesity Hyperlipidemia

% of pts.

Erythropoietin usage in PD patients (2004)

56.7

43.3

0 20 40 60

Yes No

% of pts.

(43)

Iron treatment in PD patients (2004) 44.4

15.4

40.2

0 10 20 30 40 50

Oral Parenteral None

% of pts.

Serum intact parathormone levels in PD patients (2004)

25.8

33.0

22.2

11.8

7.2 0

10 20 30 40

<100 100-300 300-500 500-1000 >1000 pg/mL

% of pts.

Phosphorus binding agents used in PD patients (2004)

6.1

20.0

56.4

Aluminium hydroxide Calcium carbonate Calcium acetate

(44)

Active vitamin D used in PD patients (2004)

37.8

2.4

59.8

0 20 40 60

Oral IV None

% of pts.

Hepatitis serology in PD patients (2004)

4.8

8.9

0.7 0

2 4 6 8 10

% of pts.

Duration of dialysis in PD patients (2004) 87.8

11.7

0.5 0.0

0 20 40 60 80 100

≤5 6-10 11-15 >15

Years

% of pts.

(45)

Causes of death in PD patients (2004)

31.3 0.5

2.2 3.3

8.2

17.3

37.1

0 10 20 30 40

Misc.

Hepatic failure Pulmonary emboli Malignancy Cerebrovascular

accident Infection Cardiovascular

Deaths due to cardiovascular diseases in PD patients (2004)

53.3

32.6

8.1 5.9

0 20 40 60

Ischemic heart disease

Heart failure Arrythmia Misc.

% of cardiovascular deaths

(46)

Discussion

 Evaluation is performed based on the results provided by 51 centers performing chronic peritoneal dialysis. There are 48 certificated PD nurses working in these centers. There are 2683 CAPD patients and 637 APD patients as of the end of 2004. The proportion of pediatric patients in CAPD and APD are 1.9% and 1.5%, respectively.

 The frequency of peritonitis is found as 29.7 patient-months and there is a significant improvement compared to last year.

 Hypertension (61.3%) and hyperlipidemia (23.4%) are the most common non-infectious

complications. Serum albumin level is lower than 3.5 g/dL in 28.9% of the PD patients. This figure is higher compared to last year.

 There is no difference in EPO usage (56.7%) in PD patients. Target HB level (<11 g/dL) is reached in only 64.6% of the patients receiving EPO. EPO resistance is found in 8.4% of PD patients. Iron treatment is administered in 59.8% of PD patients (oral: 44.4%, parenteral: 15.4%).

Routine serum ferritin tests are performed in 79.5% of the centers.

 The proportion of patients with iPTH level <100 pg/mL and >1000 pg/mL are 25.8% and 7.2%, respectively. Calcium acetate (56.4%), calcium carbonate (20%), and sevelamer (2.5%) are used as phosphorus binding agents in PD patients. There is a decrease in the rates of oral (37.8%) and IV (2.4%) active vitamin D usage compared to last year. Parathyroidectomy is performed in 47 PD patients.

 When compared to last year, there found a decrease in the frequency of HBsAg (+) and Anti-HCV (+) patients; (4.8% and 8.9%, respectively).

 With a rate of 37.1%, cardiovascular disease is the most common cause of death in PD patients and infections and cerebrovascular accidents come after, respectively. Cause of death ranking is similar to the previous years.

(47)

TRENDS IN PERITONEAL DIALYSIS THERAPY BY YEARS

Number of PD patients by years

1030 1124 1194 1111

1787 1903 1927

2556 2728 3320

0 500 1000 1500 2000 2500 3000 3500

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Count

Hypoalbuminemia (<3.5 g/dL) in PD patients by years

36.0 40.2 36.7

22.7 25.3 23.5 34.9

30.4 30.8 28.9

0 20 40 60

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

% of pts.

Erythropoietin usage in PD patients by years

(48)

Erythropoietin resistance in PD patients by years

10.0

15.3

8.4

0 5 10 15 20

2002 2003 2004

% of pts.

Iron treatment in PD patients by years

63.7 59.8

0 20 40 60 80

2003 2004

% of pts.

Active vitamin D usage in PD patients by years

47.2

56.8 53.7 56.9

47.4

38.7 42.8 40.2

0 20 40 60 80

1997 1998 1999 2000 2001 2002 2003 2004

% of pts.

(49)

Frequency of HBsAg (+) PD patients by years

5.8 14.2

11.0

9.2 10.5 8.6

7.2

5.6 5.6 5.5

0 5 10 15

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

% of pts.

Frequency of Anti-HCV (+) PD patients by years

7.3 16.7

21.3 21.3 20.8 21.3

15.1 13.8

11.3 9.6

0 5 10 15 20 25

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

% of pts.

Deaths due to cardiovascular diseases in PD patients by years

49.2

(50)

Deaths due to cerebrovascular accident in PD patients by years

13.0 12.7

10.6 10.2 9.8 11.7 13.7 11.9

8.2 15.9

0 5 10 15 20

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Deaths due to infections in PD patients by years

23.7 26.1

20.8

14.4 12.8

11.1 14.2

18.2 17.3 23.9

0 10 20 30

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Deaths due to malignancies in PD patients by years

0.6 0.6

2.5

3.4 3.2 4.7

3.8 3.3

1.8

0 1 2 3 4 5

1995 1996 1997 1998 1999 2000 2002 2003 2004

Discussion

 Starting from 1995 number of the PD patients shows an increasing trend.

 The increase in the proportion of patients receiving EPO is significant.

 Cardiovascular diseases are the most significant cause of death for 15 years.

 The proportion of HBsAg (+) PD patients varies from year to year, while the frequency of anti-HCV (+) PD patients is higher between the years 1997-2000 as compared to last 5 years.

(51)

RENAL TRANSPLANTATION

Incident RTx patients in 2004 ... 665 Male ... 68.0%

Female ... 32.0%

0-15 years of age ... 4.1%

16-19 years of age ... 5.6%

20-44 years of age ... 73.7%

45-64 years of age ... 16.7%

65+ years of age ... none Living donor ... 72.1%

Related ... 85.6%

Spouse ... 12.9%

Non-related ... 1.5%

Cadaver... 27.9%

Prevalent RTx patients as of the end of 2004 ... 3.395 Hypertension in RTx patients, as of the end of 2004

Normotensive (BP <140/90 mmHg, not on antihypertensive treatment) ... 28.2%

Cardiovascular diseases in RTx patients, as of the end of 2004

Arrythmia ... 0.9%

Hepatitis serology in RTx patients, as of the end of 2004

HBsAg (+)... 1.4%

Anti-HCV Ab (+) ... 7.9%

Status of the incident RTx patients, as of the end of 2004

Functioning graft ... 80.3%

Allograft dysfunction ... 12.6%

Returned to HD... 3.8%

Died ... 3.3%

Causes of graft loss in RTx patients, as of the end of 2004

Chronic rejection... 48.9%

(52)

Age distribution of incident RTx patients (2004)

4.1 5.6

73.7

16.7

0.0 0

20 40 60 80

0-15 16-19 20-44 45-64 65+

Years of age

% of pts.

Age distribution of incident RTx patients by donor type (2004)

2.7 4.2 69.2 22.8 0.06.5 8.1 69.7 15.7 0.0

0 20 40 60 80

0-15 16-19 20-44 45-64 65+

Years of age

% of pts.

Living Cadaver

Mean age of incident RTx patients (2004)

34.5 32.9 36.3

32.8 34.0

0 20 40

Male Female Living Cadaver Total

Years of age

(53)

Hepatitis serology in RTx patients (2004)

1.4

7.9

0.2 0

2 4 6 8 10

% of pts.

Blood pressure status in RTx patients (2004)

28.2

61.2

1.1

9.5 0

20 40 60 80

% of pts.

(54)

Cardiovascular diseases in RTx patients (2004)

0.1 0.2 0.2 0.3

0.4 0.5 0.6

0.9 1.1

11.0

0 3 6 9 12

Infective endocarditis Coronary by-pass surgery Cerebrovascular accident Acute myocardial infarction Peripheral arterial disease Heart failure Coronary angioplasty / stent Arrythmia Angina pectoris Left ventricle hypertrophy

% of pts.

Status of incident RTx patients (2004) 80.3

12.6 3.8 3.3

0 30 60 90

Functioning graft Allograft dysfunction

Returned to HD Died

% of pts.

(55)

Causes of graft loss in prevalent RTx patients (2004)

1.1 2.8

4.1 4.7

38.4

48.9

0 10 20 30 40 50

Misc.

Primary non-functioning Acute rejection Relapse of the primary disease

Death Chronic rejection

% of pts. with graft loss

Causes of death in prevalent RTx patients (2004)

4.3 6.4

25.5

51.1

Malignancy Cerebrovascular

accident Cardiovascular

Infection

(56)

Discussion

 Evaluation is performed based on the results provided by 25 centers. The number of the RTx patients on follow up is found as 3395 as of the end of 2004.

 The annual number of RTx is increased by 21.7% (n: 665). The rate of cadaver donation is 27.8%.

The rate of RTx patients younger than 15 years old is 4.1%.

 Living donations were 85.6% from relatives, 12.9% from spouse and 1.5% from non-relatives.

 The frequency of diabetic nephropathy is 3.6% in RTx patients in 2004 and diabetes mellitus is found as comorbidity in 0.8%. Only 12% of the 25 centers performed pancreas Tx in 2004.

Synchronous kidney and pancreas Tx is performed in 22 patients. The number of the Tx patients in whom kidney is transplanted first is 10.

 The number of the centers performing laparoscopic nephrectomy in living donors is 2 (8%).

 Antibody treatment is preferred for induction therapy in 58.3% (n: 388) of the RTx patients, in 2004. In 42.5% of them basiliximab, in 35.3% ATG (horse), in 18.8% daclizumab, and in 3.4%

thymoglobulin (rabbit) is administered.

 Increase in the prescribing of the new immunosuppresive agents (mycophenolate mofetil, tacrolimus, IL-2r monoclonal antibodies) will lead to more selective, efficient and safe treatment protocols.

 Hypertension is observed in 71.8% of the patients as of the end of 2004. Blood pressure is out of control in 9.5% of treated patients.

 The proportions of HBsAg (+) and Anti-HCV (+) patients are 1.4% and 7.5%, respectively, as of the end of 2004. 29.2% of the centers are performing RTx to HBsAg (+) patients, while 66.7%

performs RTx to anti-HCV (+) patients. These figures are decreased compared to last year.

 Due to the mortality analysis of the year 2004, infections are the most common cause of death (51.1%) and significantly increased compared to last year (34.8%). The most commonly observed infection is sepsis. Cardiovascular diseases, cerebrovascular accident and malignancy come after infections, respectively.

 Chronic rejection (48.9%) and death (38.4%) are the most common causes of graft loss in 2004;

there found a significant change compared to last year.

 Serum creatinin level is <2 mg/dL in 80.3% of the RTx patients while it is >2 mg/dL in 12.6% of them, in 2004. The proportion of RTx patients who returned to HD is 3.8%, and 19 patients (3.3%) died.

(57)

TRENDS IN RENAL TRANSPLANTATION BY YEARS

Number of RTx's performed by years

215 193

364 382 360 370 475

549 600

665

0 100 200 300 400 500 600 700

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Count

Distribution of RTx patients due to donor type by years

0 20 40 60 80 100

1991 1993 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

% of pts.

Living Cadaver

Frequency of HBsAg (+) RTx patients by years

3.2 4

(58)

Frequency of Anti-HCV (+) RTx patients by years

24.0 22.5 23.9

8.1

0 10 20 30

1997 1998 1999 2004

% of pts.

Deaths due to cardiovascular disease in RTx patients by years

15.7 13.3

30.4

25.5 20.0

0 20 40

1996 1998 2000 2002 2004

Deaths due to cerebrovascular accident in RTx patients by years

4.1

8.7 6.4

11.6

0 10 20 30

2000 2002 2003 2004

(59)

Deaths due to infections in RTx patients by years

43.3 44.1 45.2

40.0 51.5

34.8 32.6 53.3 51.1

0 20 40 60

1995 1996 1998 1999 2000 2001 2002 2003 2004

Deaths due to malignancies in RTx patients by years

6.7

2.9

7.2 6.1 8.6 11.6

6.7 4.3 0

10 20 30

1995 1996 1998 2000 2001 2002 2003 2004

Discussion

 The number of RTx patients has increased starting from 1995, it is still too low compared to Europe.

 We believe that this number will increase with the help of the efforts being spent by Ministry of Health in establishing a better organized Tx system.

 Through 15 years, there is no significant decrease in the proportion of HBsAg (+) patients while a significant decrease in the frequency of anti-HCV (+) patients is observed.

 Starting from 2000, there observed an increase in the percentage of the deaths due to cardiovascular diseases.

(60)

(61)

PEDIATRIC NEPHROLOGY *

Primary renal diseases in incident pediatric RRT patients in 2004 ... (n:174) Congenital urologic anomalies (including vesicoureteral reflux) ... 25.9%

Primary glomerulonephritis ... 20.7%

Neurogenic bladder ... 5.7%

Renal hypoplasia / dysplasia ... 4.0%

Secondary glomerulonephritis ... 3.4%

* Comments on the results of Pediatric Nephrology, Dialysis and Transplantation are made by

Prof. Dr. Lale SEVER (İstanbul University Cerrahpaşa Faculty of Medicine Departmant of Pediatrics Division of Clinical Nephrology)

(62)

Etiology of incident pediatric RRT patients (2004)

25.9 10.9

3.4 3.4 4.0

5.7

20.7

25.9

0 5 10 15 20 25 30

Etiology unknown Misc.

Secondary glomerulonephritis Urolithiasis Renal hypoplasia/dysplasia Neurogenic bladder Primary glomerulonephritis Congenital urologic anomalies

% of pts.

Discussion

 Pediatric patient forms are sent to 33 pediatric nephrology centers and 32 of them have responded.

 In 30 of responding centers chronic PD patients, and in 23 of responding centers chronic HD patients are being followed-up as of the end of 2004. RTx is performed in 13 of pediatric

nephrology centers, in 2004. The number of the centers with RTx patients is 15, as of the end of 2004.

 There are 61 pediatric nephrologists in 32 pediatric nephrology centers. There are 28 pediatricians continuing their education in pediatric nephrology, as of the end of 2004.

 There are more than 800 RRT patients in nephrology centers, as of the end of 2004. The percentages of PD and HD patients are 51% and 13%, respectively. The proportion of RTx patients is 36%.

 Primary renal disease is unknown in 1/4 of the incident RRT patients. Etiologic causes of ESRD congenital urologic anomalies in 1/4 and primary and secondary glomerulonephritis, each in 1/4.

(63)

PEDIATRIC HEMODIALYSIS

Prevalent pediatric regular HD patients, as of the end of 2004 ... 116 Male ... 50.0%

Female ... 50.0%

0-6 years of age... 0.8%

7-10 years of age ... 9.8%

11-15 years of age ... 49.2%

15+ years of age ... 40.2%

Frequency of HD sessions in pediatric regular HD patients, as of the end of 2004

Once weekly ... 3.3%

Twice weekly ... 12.3%

Three times weekly ... 83.6%

More than three times weekly ... 0.8%

Duration of dialysis in pediatric regular HD patients, as of the end of 2004

0-6 months ... 10.7%

7-12 months ... 6.6%

13-24 months ... 25.4%

25-60 months ... 36.1%

60+ months ... 21.3%

Types of vascular access in pediatric regular HD patients, as of the end of 2004

AV fistula ... 77.0%

Catheter ... 15.6%

AV graft ... 7.4%

Percentage of pediatric regular HD patients under antihypertensive treatment ... 52.5%

Hepatitis serology in pediatric regular HD patients, as of the end of 2004

HBsAg (+)... 7.8%

Anti-HCV Ab (+) ... 17.6%

(64)

Age distribution of prevalent pediatric regular HD patients (2004)

0.8

9.8

49.2

40.2

0 20 40 60

0-6 >6-10 >10-15 >15

Years of age

% of pts.

Types of vascular access in pediatric regular HD patients (2004)

77.0

15.6

7.4 0

20 40 60 80

AV fistula Catheter AV graft

% of pts.

Hepatitis serology in pediatric regular HD patients (2004)

7.8

17.6

2.9

0 5 10 15 20

% of pts.

(65)

Discussion

 Only 10% of the regular HD patients are younger than 10 years old. Hemodialysis duration is longer than 2 years in approximately 60% of HD patients.

 AV fistula is being used for vascular access in the vast majority of HD patients (77%).

 Proportion of HBsAg (+) pediatric HD patients is 10%, while this figure is 20% for anti-HCV Ab (+) pediatric HD patients.

(66)

(67)

PEDIATRIC PERITONEAL DIALYSIS

Prevalent pediatric PD patients, as of the end of 2004 ... 421 Male ... 47.1%

Female ... 52.9%

7-10 years of age ... 22.4%

11-15 years of age ... 33.9%

15+ years of age ... 31.5%

Duration of dialysis in pediatric PD patients, as of the end of 2004

0-6 months ... 12.1%

7-12 months ... 17.9%

13-24 months ... 21.2%

25-60 months ... 30.8%

60+ months ... 17.9%

PD treatment modality in pediatric PD patients, as of the end of 2004

CAPD ... 53.4%

APD ... 46.6%

Percentage of pediatric PD patients under antihypertensive treatment ... 63.5%

Hepatitis serology in pediatric PD patients, as of the end of 2004

HBsAg (+)... 2.7%

Anti-HCV Ab (+) ... 1.9%

Peritonitis in pediatric PD patients in 2004

Percentage of PD patients who experienced peritonitis ... 33.9%

Rate of peritonitis

All PD patients ... 1/25.7 months All CAPD patients ... 1/35.5 months All APD patients ... 1/24.3 months

(68)

PD treatment modality in pediatric PD patients as of the end of 2004

53.4

46.6

0 20 40 60

CAPD APD

% of pts.

Age distribution of prevalent pediatric PD patients (2004)

2.4

9.9

22.4

33.9 31.5

0 10 20 30 40

0-2 >2-6 >6-10 >10-15 >15 Years of age

% of pts.

Hepatitis serology in pediatric PD patients (2004)

2.7

1.9

0.5 0

1 2 3 4

% of pts.

(69)

Peritonitis in pediatric PD patients (2004)

66.1

23.5

6.1 4.3

0 20 40 60 80

None 1 2 >2

Number of episodes

% of pts.

Discussion

 One-third of the PD patients are younger than 10 years old, as of the end of 2004. PD duration is more than 2 years in nearly 50% of the patients. PD duration for 18% of the patients is more than 5 years.

 The proportion of APD patients is 47%.

 The proportions of positivity of hepatitis serology are lower than HD patients; HBsAg (+) 3.2% and anti-HCV Ab (+) 2.4%.

 Average peritonitis rate is found as 1/25.7 patient-months.

(70)

(71)

PEDIATRIC RENAL TRANSPLANTATION

Incident pediatric RTx patients in 2004 ... 59 Male ... 50.8%

Female ... 49.2%

7-10 years of age ... 6.8%

11-15 years of age ... 45.8%

15+ years of age ... 42.4%

Living donor ... 50.8%

Cadaver... 49.2%

Prevalent pediatric RTx patients, as of the end of 2004 ... 279 Duration of waiting of pediatric patients transplanted in 2004

Preemptive Tx ... 12.7%

<6 months ... 20.8%

6-12 months ... 5.5%

13-24 months ... 25.5%

25-60 months ... 29.1%

>60 months ... 7.3%

(72)

Age distribution of incident pediatric RTx patients (2004)

5.1 6.8

45.8 42.4

0 20 40 60

0-6 >6-10 >10-15 >15

Years of age

% of pts.

Duration of waiting of pediatric patients transplanted (2004)

12.7

20.8

5.5

25.5

29.1

7.3

0 20 40

Preemptive Tx

<6 months 6-12 months

13-24 months

25-60 months

>60 months

% of pts.

Discussion

 The number of RTxs performed in 2004 is 59. This figure is similar to the last year. The donors in half of the RTxs are living related donors.

 The duration of waiting on dialysis is more than 2 years in 36% of pediatric RTx patients.

(73)

Comparative Figures from World and Turkey

(74)

(75)

Figure 1. Worldwide incident rates (per million population)* (USRDS 2004).

* Data represent the most current information available (primarily 2002). Data from Israel, Japan, Luxembourg, & Taiwan represent dialysis only.

(76)

Figure 2. European countries/regions contributing to ERA-EDTA Registry (ERA-EDTA registry newsletter, December 2004).

Registries contributing individual patient data to the ERA-EDTA Registry database Registries sending aggregated data to be included in the annual report

No registry / no contribution / data not eligible for analysis

(77)

Figure 3. Incidence of ESRD in some countries in 2003 (USRDS 2004).

122

Spain/Basque Country Norw ay Australia Malaysia Poland Netherlands Scotland New Zealand Croatia Turkey Sw eden Chile Denmark Korea (Repub of) Austria Uruguay Luxembourg Spain/Catalonia Canada Spain/Valencia Spain/Canary Islands Greece Belgium Germany Israel Qatar Japan United States Taiw an

(78)

Figure 4. Prevalence of ESRD in some countries in 2003 (USRDS 2004).

387.5

0 300 600 900 1200 1500 1800

Philippines Bangladesh Russia Latvia Turkey Poland Malaysia Iceland Luxembourg Qatar Finland Norw ay Netherlands Australia Israel New Zealand Croatia Scotland Korea, Republic of Denmark Chile Sw eden Austria Uruguay Greece Belgium Spain/Basque Country Canada Germany Spain/Canary Islands Spain/Catalonia Spain/Valencia United States Taiw an Japan

Rate per million population

(79)

Figure 5. Prevalent dialysis patients by modality in some countries in 2003 (USRDS 2004).

Denmark Scotland Korea Finland Canada Norw ay Turkey Malaysia Belgium Poland Israel Greece Qatar Spain/Canary Islands Croatia United States Austria Spain/Valencia Taiw an Russia Uruguay Germany Spain/Catalonia Chile Japan Luxembourg Bangledesh

In-center HD Home HD PD

REGISTRY OF THE NEPHROLOGY, DIALYSIS AND TRANSPLANTATION IN TURKEY

PUBLISHED BY THE TURKISH SOCIETY OF NEPHROLOGY