Nephrol Dial Transplant (1998) 13: 860–864
Nephrology
Dialysis
Transplantation
Dialysis and Transplantation News
Evolution of renal replacement therapy in Central and Eastern Europe
7 years after political and economical liberation*
Boleslaw Rutkowski (Gdansk, Poland), Alexandru Ciocalteu (Bucarest, Romania), Ljubica
Djukanovic (Belgrade, Yugoslavia), Istvan Kiss (Budapest, Hungary), Aleksander Kovac (Bratislava,
Slovakia), Stefan Krivoshiev (Sofia, Bulgaria), Rado Kveder (Ljubliana, Slovenia), Momir
Polenakovic (Skopje, Macedonia), Zvonimir Puretic (Zagreb, Croatia), Maria Stanaityte ( Vilnius,
Lithuania), Irina Tareyeva (Moscow, Russia), Vladimir Teplan (Prague, Czech Republic)—Central
and Eastern Europe Advisory Board in Chronic Renal Failure—and Jeff Zavitz (Janssen–Cilag, Zug,
Switzerland)
Abstract
Purpose of the study. The conditions of renal
replacement therapy (RRT ) were very poor in the
countries located in Central and Eastern Europe (CEE )
when they were members of the so-called ‘socialist
bloc’. The aim of the present analysis was to document
the impact of the socioeconomic changes on dialysis
therapy in the CEE countries.
Design. This was a special survey with the
participation of 12 CEE countries, with data obtained
through national registries (with the exception of
Russia).
Results. During the period 1990–1996 the number of
haemodialysis units increased by 56% and the number
of centres performing peritoneal dialysis by 296%. The
number of patients increased respectively by 78%
(haemodialysis) and 306% (peritoneal dialysis). The
percentage of patients with diabetic nephropathy and
elderly patients rose dramatically during this period.
One of the main reasons of such expansion was the
rapid development of peritoneal dialysis programmes
in the majority of the CEE countries. The introduction
of modern haemodialysis machines and a wider choice
of different dialysers and concentrates permitted individualization of dialysis procedures. These points and
the wider use of erythropoietin had a positive influence
on quality of life and treatment outcome. There was
also a notable increase in the number of transplant
centres, but less so of the number of transplanted
patients.
Conclusion. Renal replacement therapy experienced a
major expansion in the CEE countries. Despite the
progress achieved, the level of RRT is not yet
completely satisfactory in most CEE countries.
Correspondence and offprint requests to: Prof. Boleslaw Rutkowski,
Department of Nephrology, Medicine University, Debinki 7, 80–211
Gdansk, Poland.
*This article is commented upon in the subsequent contribution
Key words: renal failure; haemodialysis; peritoneal
dialysis; development
Introduction
Dialysis and renal transplantation are the cornerstones
of renal replacement therapy (RRT ) [1]. Availability
of these techniques varies widely between different
regions of the world. Nearly 80% of dialysed patients
are treated in the United States, Canada, Japan and
the European Community. Similarly, the major proportion of renal transplantations are performed in
these countries [2–4].
The rest of the world, comprising more than 80% of
the world’s population, has only limited access to
such treatment. Not surprisingly, differences in the
economical situation are the major reason for such
discrepancies, since RRT is one of the most expensive
medical procedures [5,6 ].
For many years the countries in Central and Eastern
Europe were members of the so-called socialist bloc,
the economy of which was notoriously inefficient.
Consequently, conditions were very unfavourable for
the effective use of RRT in these countries. The situation was best (or rather less catastrophic) in former
Czechoslovakia and Hungary; it was worse in Bulgaria
and Poland and worst of all in Albania and the Soviet
Union. Political and socioeconomic changes took place
at the end of the 1980s and beginning of 1990s and
many new countries came into existence or gained full
sovereignty. Simultaneously these countries introduced
open-market economies. These changes influenced
many aspects of life for people living in this area. This
included the conditions of health care.
The aim of the present study was to assess the
changes of RRT that followed such economic changes
in Central and Eastern Europe.
© 1998 European Renal Association–European Dialysis and Transplant Association
RRT in Central and Eastern Europe
861
Subjects and methods
All data were obtained in a special survey among the
members of the Central and Eastern Europe Advisory Board
in Chronic Renal Failure, using specially prepared questionnaires. The Advisory Board was created in September 1996
as a part of the Special Research Programme sponsored by
Janssen–Cilag (Zug, Switzerland ) with technical assistance
of Excerpta Medica (Amsterdam, Holland ). The questionnaires included items concerning the number of dialysis units,
stations, and patients on treatment, as well as use of different
modalities of RRT (haemodialysis, peritoneal dialysis, renal
transplantation). Further questions covered some specific
topics including number of patients with diabetic nephropathy, frequency of hepatitis among dialysed patients, use
of erythropoietin etc.
With one exception the board members were able to
complete the questionnaires, using data available from their
national registries (Czechoslovakia, Poland) or from annual
surveys of the presidents of their nephrological societies. The
information from Russia was fragmentary, because a national
registry does not yet exist in this country. For this reason,
figures from Russia are not included in this analysis.
Results
The number of haemodialysis and peritoneal dialysis
units is presented in Figure 1. During the past 6 years,
possibilities of dialysis treatment improved significantly
in all countries analysed. The number of haemodialysis
units increased by 56% and the number of centres
performing peritoneal dialysis by 296%. Significant
changes were also observed in the number of patients
treated by these two modalities of dialysis (Figure 2).
The number of patients increased by 78% (haemodialysis) and by 306% (peritoneal dialysis) respectively. It
has to be mentioned that not only quantitative, but
also qualitative changes were achieved, because more
than 56% of machines used are now modern and
produced within the past 4 years. In the majority of
haemodialysis centres, procedures such as bicarbonate
dialysis, controlled ultrafiltration, and sodium profiling
are available. Also a wide range of dialysers and
concentrates are used in most of the countries. The
percentage of patients with diabetic nephropathy
treated with either modality of dialysis is presented in
Figure 3. The number of patients on treatment
increased dramatically, especially for patients on peritoneal dialysis.
Renal transplantation activity in Central and Eastern
Europe is summarized in Figure 4. The number of
transplant units has almost doubled during the past
2 years, but the increase in the number of renal
transplantations was not entirely satisfactory, especially when taken against the increasing number of
patients on the waiting list.
Data on the prevalence of patients maintained on
different dialysis modalities per 1 million of population
are shown in Table 1. These global figures hide some
striking differences between countries. In Slovenia the
rate is almost 500 p.m.p., in Macedonia 400 p.m.p., in
Fig. 1. Number of haemodialysis (HD) and peritoneal dialysis (PD)
units in Central and Eastern Europe during the period 1990–1996.
the Czech Republic more than 300 p.m.p., in Poland
145 p.m.p., and in Lithuania 77 p.m.p.
Discussion
The above data document a dramatic increase in the
availability of RRT in the Central and Eastern
European countries, subsequent to the recent political
and socioeconomic changes. Such increase was not
uniform, however, and the highest number of patients
maintained on dialysis is currently found in Slovenia,
the Czech Republic, Hungary and Slovakia. The proportionally most striking progress during the past years
was achieved in Poland, however [7–9]. The possibilities of RRT in Albania, Russia and the post-Soviet
countries are still far from satisfactory [10,11].
The magnitude of change is not well reflected by the
mere numbers. There has also been a dramatic change
in the quality of dialysis treatment. Modern newly
manufactured dialysis machines were installed in nearly
all new dialysis units and in many of the existing ones.
This permitted not only more reliable and more effi-
862
B. Rutkowski et al.
Fig. 2. Number of patients dialysed using haemodialysis (HD) and
peritoneal dialysis (PD) in Central and Eastern Europe during the
period 1990–1996.
Fig. 3. Percentage of dialysed patients with diabetic nephropathy.
cient treatment; but also an increase of the patient
load and improved the patients’ quality of life.
Bicarbonate dialysis, controlled ultrafiltration, sodium
profiling, various dialysers (including the more
biocompatible ones), and various concentrates have
become available and permit individualization of treatment. One striking aspect is the increase in peritoneal
dialysis. Several years ago this procedure was very
limited in Central and Eastern Europe. During the
past years its use has increased dramatically. In parallel, automated peritoneal dialysis (CCPD) has also
been started in several centres. These alternative modalities are used mainly for special groups of patients; e.g.
in Poland, most children with end-stage renal disease
are treated using peritoneal dialysis. Amongst adult
patients, CAPD is used mainly in diabetic patients,
elderly people, and patients with cardiovascular instability [12,13].
There are interesting demographic differences
between Central and Eastern Europe on the one hand
and USA, Japan, or Western Europe on the other
[1,3,4,8]. The mean age of dialysed patients is much
lower in Central and Eastern Europe, but the proportion of elderly people treated has risen significantly
during the past few years. The same is true for diabetic
patients. Of note, diabetic patients constitute currently
RRT in Central and Eastern Europe
863
Fig. 4. Renal transplantation in Central and Eastern Europe.
11% of haemodialysed patients and 22% of patients
on CAPD. These proportions are lower than those in
the USA or Western Europe, but these figures should
be compared with the proportions encountered 6 years
ago, i.e. 4.4% and 2.5% respectively. It is only in the
Czech Republic and Slovakia that the proportion of
diabetic patients amongst dialysed patients approaches
the figures reported from Germany or France [4], i.e.
25% in the Czech Republic and 17.9% in Slovakia.
The change in patient mix must be taken into
consideration when assessing future trends of the
ESRD population [14–16 ]. In the past, the gross
mortality rate on dialysis was quite low and comparable with that reported from more developed countries
of the world, and was even lower than that reported
from the USA [1,4,17], but we acknowledge that the
patients on treatment in Central and Eastern Europe
had been strikingly younger.
One should also point to the improvement in the
quality of life of the patients treated in Central and
Eastern Europe. A few years ago, erythropoietin was
introduced and is now given to approximately 60% of
dialysed patients.
One unsatisfactory aspect is the underdevelopment
of renal transplantation. This is mainly ascribed to
lack of sufficient donors. Although this phenomenon
has been observed in many countries throughout the
world, it is particularly prominent in our region
[1,4,8,10]. In the future it will be necessary to adopt
living-related donors more widely, to better organize
organ retrieval and to change the attitude of the public
towards renal transplantation. This is a worthwhile
effort, since the results of renal transplantation, at least
in the majority of our countries, are comparable with
those achieved in developed countries [1,4,8].
Unfortunately, dialysis is linked to money and the
reimbursement system is a very important aspect. In
most of the analysed countries, reimbursement is still
mainly based on central (Ministry of Health) or local
budgets. Increasingly, however, insurance systems are
introduced. In the majority of countries, the development of RRT is not (or at least not only) based on
local or regional budgets, but on national programmes
funded by the governments [7,18]. It follows that the
development of RRT will strongly depend on the
future economic development in the respective countries. It will be an important issue to make local
regional and central authorities aware of the problems
of RRT through publicity and pressure from the
nephrological communities, patients, staff and doctors.
We conclude that (i) in the past 5–6 years significant
progress concerning development of dialysis facilities
has occurred in Central and Eastern Europe.
ii) Further development of all treatment modalities is
necessary to achieve acceptance rates comparable to
those of developed countries. (iii) Special national
Table 1. Rate of dialysis per million population in Central and Eastern Europe
Population (106)
HD units
HD patients
PD patients
(11 countries)
p.m.p.
p.m.p.
p.m.p.
HD+PD
patients
p.m.p.
119.3
4.5
206.2
13.9
220
HD, haemodialysis; PD, peritoneal dialysis; p.m.p., per million population.
864
programmes based on central funding appear to be
the best solution in countries with underdeveloped
health structures.
Acknowledgements. All authors are key persons responsible for the
development of renal replacement therapy in their countries and
members of the Central and Eastern Europe Advisory Board in
Chronic Renal Failure. B. Rutkowski is a chairman of the Board.
The study was partially supported by the special research grant from
Janssen–Cilag, Zug, Switzerland. Technical assistance of Jacki Arnet
(Janssen–Cilag), Karen Tkach and Marike Westra ( Excerpta
Medica, Amsterdam, Holland) in preparation and providing of the
survey and Richard Beswick in statistical analysis of the data are
gratefully acknowledged.
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