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Vol. 36. Issue. 2.March - April 2016
Pages 89-216
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Vol. 36. Issue. 2.March - April 2016
Pages 89-216
Special article
DOI: 10.1016/j.nefroe.2016.04.008
Open Access
The Spanish Renal Registry: 2013 report and evolution from 2007 to 2013
Registro Español de Enfermos Renales. Informe 2013 y evolución 2007-2013
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Eduardo Martín Escobar, Registro Español de Enfermos Renales (REER)
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Tables (22)
Table 1. Coverage of the population of Spain by the REER.
Table 2. Incidence by gender and initial renal replacement treatment modality in 2013.
Table 3. Incidence by age group in 2013 (PMP).
Table 4. Age-adjusted incidence (EU27, 2005) 2013 (PMP).
Table 5. Distribution of PRD in each age group. 2013.
Table 6. Distribution by age group of PRD. 2013.
Table 7. Overall incidence, unadjusted rate 2007 to 2013 (PMP).
Table 8. Evolution of the percentage of the different initial RRT modalities 2007–2013.
Table 9. Prevalence by sex and initial renal replacement treatment modality in 2013.
Table 10. Prevalence by age group in 2013 (PMP).
Table 11. Age-adjusted prevalence (EU27, 2005) 2013 (PMP).
Table 12. Overall prevalence, unadjusted rate PMP 2007 to 2013 (PMP).
Table 13. Evolution of the percentage of the different RRT modalities in prevalent patients 2007–2013.
Table 14. Kidney transplants by AR of the transplant centre. 2013.
Table 15. Kidney transplants overall and by AR 2007–2013.
Table 16. Evolution of annual mortality 2007–2013, by treatment modality (%).
Table 17. Distribution by AR of the incident patients 2004–2012 included in the survival analysis.
Table 18. Distribution by year of the incident patients 2004–2012 included in the survival analysis.
Table 19. Characteristics of the patients included in the survival analysis 2004–2012.
Table 20. Unadjusted survival.
Table 21. Cox model.
Table 22. Evolution of kidney transplants 2006–2012.
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Abstract

The purpose of the study is to show the evolution of renal replacement therapy (RRT) in Spain from 2007 to 2013.

Aggregated data and individual patient records were used from participating regional renal disease registries and that National Transplant Organisation registry. The reference population was the official population on January 1st of each year studied. Data on incidence and prevalence were based on aggregated data, while the survival analysis was calculated from individual patient records. The study period was 2007–2013 for prevalence, incidence and transplantation, and survival was analysed for 2004–2012. The population covered by the registry was a minimum of 95.3–100% of the Spanish population for aggregated data. The EU27 age and gender distributions of the European population for 2005 were used to adjust incidence and prevalence for age and gender. Survival probabilities were calculated for incident patients between the years 2004 and 2013 using the Kaplan–Meier method to calculate unadjusted patient survival probability. The log rank test was applied to compare survival curves according to some risk factors. Cox proportional hazards model was created to study the potential predictors of survival.

In 2013, the total number of patients in Spain that started RRT was 5705 for 95.3% of the total Spanish population, with an unadjusted rate of 127.1PMP. The evolution from 2007 to 2013 showed a gradual decline from 127.4PMP in 2007 to 120.4PMP in 2012, with a small upturn to 127.1 in 2013. The adjusted incidence rate for the year 2013 was 121.5PMP for the total population, 158.7PMP for males and 83.1PMP for females. The most frequent cause of primary renal disease in incident was diabetes mellitus: 20.4% in 2007, which increased to 24.6% in 2013. The percentage of transplant as first RRT increased from 1.7% in 2007 to 4.2% in 2013. The total number of patients in RRT for 95.3% of the population in 2013 was 50,567, with an unadjusted prevalent rate of 1125.7PMP. The adjusted prevalence rate for 2013 was 1087.5PMP (1360.7PMP for males and 809.8PMP for females). The percentage of diabetes mellitus in prevalent patients evolved from 13.9% in 2007 to 14.9% (168PMP) in 2013. The percentage of transplanted prevalent patients with functioning grafts evolved from 49.3% in 2007 to 51.5% in 2013. The number of transplantations performed each year increased from 2211 (48.9PMP) in 2007 (6.2% living donor transplants) to 2552 (54.2PMP) in 2013 (15.0% living donor transplants).

40,394 patients from 12 regions of Spain who began RRT between 2004 and 2012 were included in the survival analysis (87% Spanish population coverage). Unadjusted patient survival probabilities after one, 2 and 5 years were 91, 81 and 57%, respectively. In the univariate analysis, better survival was found for non-diabetic patients, women, age below 45, peritoneal dialysis as first RRT and patients who had received at least one transplant.

Keywords:
End-stage renal disease
Renal replacement therapy
Incidence
Prevalence
Kidney transplantation
Survival
Resumen

El objetivo del estudio es mostrar la evolución del TRS en España desde 2007 hasta 2013.

Se utilizaron datos agregados y registros individuales de pacientes de los registros de enfermedades renales de las comunidades autónomas participantes, y el registro de la Organización Nacional de Trasplantes. La población de referencia fue la población oficial a 1 de enero de cada año estudiado. La incidencia y la prevalencia se basan en datos agregados, mientras que el análisis de supervivencia se calculó a partir de registros individuales. El período de estudio fue 2007-2013 para prevalencia, incidencia y trasplante; y 2004-2012 para el análisis de supervivencia. La población cubierta por el registro fue un mínimo del 95,3-100% de la población española para datos agregados. La distribución de edad y sexo de la población europea (UE-27) para el año 2005 se utilizó para ajustar incidencia y prevalencia. Se calcularon las probabilidades de supervivencia de los pacientes incidentes entre 2004 y 2013, utilizando el método de Kaplan-Meier para calcular la probabilidad de supervivencia sin ajustar. Las curvas de supervivencia se compararon mediante log rank test de acuerdo con algunos factores de riesgo. Se construyó un modelo proporcional de Cox para estudiar los posibles predictores de supervivencia.

En 2013 el número total de pacientes en España que iniciaron TRS fue de 5.705 para un 95,3% del total de la población española; con una tasa no ajustada de 127,1pmp. La evolución desde 2007 hasta 2013 mostró una disminución gradual, de 127,4pmp en 2007 a 120,4pmp en 2012, con un pequeño repunte a 127,1 en 2013. La incidencia ajustada para el año 2013 fue de 121,5pmp total, 158,7pmp para hombres y 83,1pmp para mujeres. La causa más frecuente de enfermedad renal primaria en incidentes fue la diabetes mellitus: el 20,4% en 2007, aumentando al 24,6% en 2013. El porcentaje de trasplante, como primera TRS, aumentó del 1,7% en 2007 al 4,2% en 2013. El número total de pacientes en TRS, respecto al 95,3% de la población, en 2013 fue de 50.567, con una tasa de prevalencia no ajustada de 1.125,7pmp. La tasa de prevalencia ajustada para 2013 fue 1.087,5pmp, 1.360,7pmp para varones y 809,8pmp para mujeres. El porcentaje de diabetes mellitus en pacientes prevalentes evolucionó del 13,9% en 2007 al 14,9% en 2013. El porcentaje de pacientes prevalentes trasplantados y con injerto funcionante pasó del 49,3% en 2007 al 51,5% en 2013. El número de trasplantes realizado cada año aumentó de 2.211 (48,9pmp) en 2007, con un 6,2% de trasplantes de donante vivo, a 2.552 (54,2pmp) en 2013, con un 15% de trasplantes de donante vivo.

Se incluyeron en el análisis de supervivencia 40.394 pacientes procedentes de 12 regiones que comenzaron su TRS entre 2004 y 2012 (un 87% de cobertura de la población española). Las probabilidades de supervivencia sin ajustar de los pacientes, a uno, 2 y 5 años, fueron del 91, 81 y 57% respectivamente. En el análisis univariado se encontró una mejor supervivencia en pacientes no diabéticos, de sexo femenino, edad inferior a 45 años, siendo la diálisis peritoneal el primer TRS y que hubieran recibido al menos un trasplante.

Palabras clave:
Enfermedad renal crónica terminal
Tratamiento renal sustitutivo
Incidencia
Prevalencia
Trasplante renal
Supervivencia
Full Text
Introduction

Since the publication of the 2006 Spanish Renal Registry (REER) report in Nefrología1 in 2009, we have not published any additional report, although we have presented a yearly report at the Spanish Society of Nephrology (SEN) Congress. Also the information has been available in the website of the SEN2 as a presentation. During these years we have also developed our own website3 that collects annual incidence and prevalence data separated by modality of renal replacement treatment (RRT) including each autonomous regions (ARs) of Spain and the global data for Spain. We maintain our collaboration with the European ERA-EDTA registry4 and with the North American USRDS registry,5 as the reference from Spain. Since 2012 (2011 report),6 the yearly report at the SEN Congress includes survival data in patients in RRT since 2004, compiling data from the ARs registries that was made available.

In recent years, a new codification of primary renal disease (PRD) has been developed by the ERA-EDTA Registry, with the collaboration of one member of our REER. Subsequently, the REER collaborated in its translation into Spanish published in Nefrología.7 The new coding provides a simpler system to achieve a more precise diagnosis of renal disease, including codes and terms for most renal diseases whether or not may progress end-stage renal failure. It also has the advantage of including the latest advances on renal disease, as well as a direct link to CIE-10 codes and SNOMED identifiers.

The aim of the present REER report is to illustrate the situation of end-stage renal disease (ESRD) in Spain in 2013. Through analysis of the evolution of the epidemiological parameters during recent years, we want to outline the possible evolution of the disease and RRT in the near future.

MethodologySources of data

  • Annual collection of aggregated and individualised data from the renal registries of the participating ARs. It was not possible to include data from the autonomous region of the Canary Islands in 2013 since in 2013 and 2014 the databases and electronic storage medium were being transferred to the Canary Islands Health Service, which is now analysing the registry.

  • Donation and transplant registry of the Spanish Transplant Organisation.

  • Reference population of Spain and each autonomous region: the official data on population is provided on 1 January of the year, published by the Spanish Official State Bulletin (BOE).8–14 Distribution of population by age group, obtained from the Spanish Statistical Office (INE) website.15

The incidence and prevalence data were calculated based on the aggregated data, while the survival analysis was performed based on the data on individual patients from the registries provided by the autonomous regions.

Study period

  • 2007–2013 for prevalence, incidence and transplants.

  • 2004–2012 for the survival analysis.

Definitions

The definitions used were those agreed upon by the Spanish Group of Registries of Renal Diseases (GRER)16 and, if not available, the definitions of the ERA-EDTA Registry.17

  • Incidence: Number of patients who started RRT during the specified period; in this report it was in a year period during 2007–2013.

  • Prevalence: Total number of alive patients in RRT on 31 December of the corresponding year with residence in each of the ARs.

Incidence and prevalence rates are expressed as patients per million of the population (PMP).

MethodsRates of incidence and prevalence

  • Non adjusted rates: number of incident or prevalent patients divided by the general population in the specific year and multiplied by one million. The rates are presented stratified by PRD, type of replacement therapy, sex and age group.

  • Adjusted rates: We use the distribution by age and gender of the European population in 2005 (EU27)18 for the total in Spain and each AR to adjust the rates using the direct method.

Kidney transplants performed

The number of kidney transplants was recorded from the donation and transplant registry of the Spanish Transplant Organisation19 and the data was presented stratified by donor type (living, deceased by neurological criteria—brain death—or deceased by circulatory and respiratory criteria—asystole).

Methods for survival analysis

It was based on data on individual patients provided by the ARs with specific consent to be use for analysis. To merge all data, an initial process of data purging and conversion was performed until a uniform format was obtained that allowed the analysis of variables.

Patients incident between 2004 and 2012, over 15 years of age and with a follow-up greater than 3 months were included. Patients with a kidney transplant as a first RRT and patients from other registries were excluded.

For description of the patients included in the survival analysis, mean, median and standard deviation were used for the quantitative variables and percentages and frequencies were used for the categorical variables. The Kaplan–Meier method was used to calculate the unadjusted probability of survival, and the log-rank test was used to compare the survival curves between groups. A Cox proportional hazards model was developed to study factors potentially predictive of survival using the following as adjustment variables: age, sex, RRT modality, diabetic nephropathy as PRD and having received at least one transplant.

Death was considered to be an event, censoring the recovery of renal function, transfer to another registry and the loss to follow-up. The analysis was done by intention to treat.

The software programs used were Microsoft Excel and SPSS v.15.0 for Windows.

Results

The total population covered by the registry has varied from year to year, from at least 95.3% to 100% of the total population in Spain for the aggregated incidence and prevalence data (Table 1).

Table 1.

Coverage of the population of Spain by the REER.

  Year
  2007  2008  2009  2010  2011  2012  2013 
Population  45,200,737  46,157,822  46,745,807  47,021,031  47,190,493  47,265,321  47,129,700 
Population covered  43,415,981  44,296,880  44,804,102  45,559,052  47,095,618  47,265,321  44,916,825 
% Coverage  96.1  96  95.8  96.9  99.8  100  95.3 

REER: The Spanish Renal Registry.

Incidence

In 2013 the total number of patients who started RRT due to ESRD was 5705, for a 95.3% of the total population of Spain. This represents an unadjusted rate of 127PMP. The lowest rate was in Castilla-La Mancha with 102.3PMP, and the highest rate was that of Asturias with 158.2PMP (Table 2). Among incident patients, 3746 (65.7%) were men and 1959 (34.3%) were women, and the rate was 200.9PMP for men and 102.4PMP for women (Table 2), so in Spain, for every woman that started RRT, there were 1.9 men who did so. The value varied according to AR; from 1:1 in Melilla up to 2.7 men for each woman in Cantabria and in Castilla y León. By age group, the incidence increased in both men and in women, reaching 414.9PMP in patients over 75 years of age (Table 3). The age-adjusted incidence rate was 121.5PMP overall, 158.7PMP for men and 83.1 for women, with a wide variation among ARs (Table 4 and Fig. 1).

Table 2.

Incidence by gender and initial renal replacement treatment modality in 2013.

  TotalGenderInitial treatment
        NPMPNPMP
  Population  N  PMP  Male  Female  Male  Female  HD  PD  ETX  HD  PD  ETX 
Andalusia  8,440,300  1043  123.6  655  388  157  90.9  845  160  38  100.1  19  4.5 
Aragon  1,347,150  168  124.7  112  56  167.2  82.7  135  30  100.2  22.3  2.2 
Asturias  1,068,165  169  158.2  121  48  236.6  86.2  125  42  117  39.3  1.9 
Balearic Islandsa  1,017,395  144  141.5  91  53  179.3  103.9  123  10  11  120.9  9.8  10.8 
Cantabria  591,888  63  106.4  46  17  159.4  56.1  38  14  11  64.2  23.7  18.6 
Castile and León  2,519,875  270  107.1  197  73  158.1  57.3  220  44  87.3  17.5  2.4 
Castile-La Mancha  2,100,998  215  102.3  136  79  128.7  75.7  163  51  77.6  24.3  0.5 
Catalonia  7,553,650  1095  145  719  376  193  98.2  873  143  79  71.1  18.7  0.7 
Autonomous Community of Valencia  5,113,815  683  133.6  434  249  171.2  96.5  537  141  170.7  28  15.4 
Extremadura  1,104,004  137  121.4  97  40  173.3  70.2  118  18  106.9  16.3  0.9 
Galicia  2,765,940  393  142.1  264  129  197.7  90.2  291  83  19  105.2  30  6.9 
Madrid  6,495,551  780  120.1  505  275  161.7  81.6  630  110  40  97  16.9  6.2 
Murcia  1,472,049  160  108.7  107  53  144.6  72.4  125  33  84.9  22.4  1.4 
Navarra  644,477  69  107.1  48  21  149.6  64.9  53  15  82.2  23.3  1.6 
Basque Country  2,191,682  262  119.5  183  79  171.2  70.4  178  66  18  81.2  30.1  8.2 
La Rioja  322,027  37  114.9  22  15  137.4  92.7  28  86.9  24.8  3.1 
Ceutab  84,180  12  142.6  162.6  121.6  12  142.6 
Melillab  83,679  95.6  93  98.4  95.6 
Total in Spain  44,916,825  5708  127.1  3746  1959  200.9  102.4  4502  968  238  100.2  21.6  5.3 

PD: peritoneal dialysis (all modalities); HD: haemodialysis (all modalities); N: total number of cases; PMP: patients per million of the population; ETX: early kidney transplant.

a

The population covered on the Balearic Islands excludes the population of the Island of Menorca, which did not provide any data.

b

The autonomous cities of Ceuta and Melilla provide care for patients from neighbouring Morocco.

Table 3.

Incidence by age group in 2013 (PMP).

  0–14  15–44  45–64  65–74  >75 
Andalusia  6.5  39.6  172.8  399.8  387.4 
Aragon  10.7  15.1  136.6  343.7  444 
Asturias  38.9  193.9  386.8  362.8 
Balearic Islands  33.2  180.6  524.6  579.7 
Cantabria  52.3  124.7  388.3  159.1 
Castile and León  23.9  107.2  315.6  276.6 
Castile-La Mancha  26.1  140.1  243  378.1 
Catalonia  11  34.3  162.7  470.6  535.1 
Autonomous Community of Valencia  5.2  35.9  145.5  397.6  499.6 
Extremadura  6.3  29.6  163.9  304.9  387.4 
Galicia  39.3  172.2  365.5  331.2 
Madrid  4.9  39.7  151.3  365  440.2 
Murcia  3.8  38.7  147.4  399.6  366.8 
Navarra  31.1  147.8  290.3  323.6 
Basque Country  46.3  115.3  312.2  370.9 
La Rioja  23.5  82.1  583.7  327.6 
Ceuta  80.1  149  395.1  969.2 
Melilla  79.9  51.8  467.7  517.3 
Total in Spain  5  36  153.1  384.6  414.9 

PMP: patients per million of the population.

Table 4.

Age-adjusted incidence (EU27, 2005) 2013 (PMP).

  Male  Female  Total 
Ceuta  208.5  149  180.4 
Balearic Islands  187.5  110.9  151.1 
Catalonia  184.4  95.6  140.5 
Melilla  111.1  142.6  128.4 
Asturias  186.6  71.2  127.9 
Andalusia  138.7  94.4  127 
Autonomous Community of Valencia  157.2  93.2  126.6 
Madrid  163.1  83.4  122.2 
Galicia  158.9  77.6  118.3 
Murcia  155.7  79.3  118.2 
Extremadura  152.6  67.7  111.8 
La Rioja  126  88.9  108.6 
Aragon  158.5  73  107.4 
Basque Country  146  64  105 
Navarra  136.8  63.2  101.2 
Cantabria  149.8  51.8  100.9 
Castile-La Mancha  120.3  71.2  97 
Castile and León  124.4  46.1  86.8 
Total in Spain  158.7  83.1  121.5 

PMP: patients per million of the population.

Fig. 1.

Age-adjusted incidence 2013.

(0.2MB).

As far as RRT modality, in 2013, 78.9% of patients started in some modality of haemodialysis (HD), 16.9% started in peritoneal dialysis (PD) and 4.2% had an early kidney transplantation. HD rates was 100.2PMP, PD 21.6PMP and early kidney transplant 5.3PMP. Again, a wide variation was observed among the different ARs (Table 2 and Fig. 2).

Fig. 2.

Distribution of initial RRT modalities by AR.

(0.19MB).

By PRD, 24.6% of incident patients had the diagnosis of diabetes mellitus (DM); classified as PRD of unknown origin (UO) were 20.9%; vascular diseases, including hypertension (vascular and/or hypertensive nephropathy [VHN]), represented a 16.2%; and glomerular disease (glomerulonephritis) were only 12.3% of incident patients (Table 5). DM was the most common PRD (29.2%) in patients who started RRT between 65 and 74 years old, and VHN (24.8%) and UO (27.8%) were the most common PRDs in the group patients with more than 75 years (Table 5). However, the greatest percentage of DM (33.9%) was in the group of 45 to 64 years of age, and the percentage of UO increased with the age group reaching a 40.7% in those over 75 years old (Table 6 and Figs. 3 and 4).

Table 5.

Distribution of PRD in each age group. 2013.

  GN (%)  CPN/CIN (%)  DM (%)  VHN (%)  PKD (%)  HDs (%)  SDs (%)  Other (%)  UO (%)  Total (%) 
0–14  14.71  17.7  2.9  5.9  29.4  2.9  11.8  14.7  100 
15–44  22.4  12.5  16.7  7.1  8.3  5.3  7.1  3.3  17.4  100 
45–64  16.5  8.4  26.5  10.7  13  1.7  4.7  3.3  15.3  100 
65–74  10.1  8.7  29.2  17.1  4.5  1%  4.8  3.6  21.1  100 
>75  7.6  22.1  24.8  0.5  4.4  3.94  27.9  100 
Adults  12.3  8.7  24.7  16.3  7.2  1.6  4.9  3.6  20.9  100 
Total  12.3  8.8  24.6  16.2  7.2  1.7  4.9  3.6  20.9  100 

DM: diabetes mellitus; HDs: hereditary diseases; PRD: primary renal disease; SDs: systemic diseases; GN: glomerulonephritis; VHN: vascular and/or hypertensive nephropathy; CPN/CIN: chronic pyelonephritis/chronic interstitial nephropathy; PKD: polycystic kidney disease; UO: unknown origin.

Table 6.

Distribution by age group of PRD. 2013.

  GN (%)  CPN/CIN (%)  DM (%)  VHN (%)  PKD (%)  HDs (%)  SDs (%)  Other (%)  UO (%)  Total (%) 
0–14  0.7  1.2  0%  0.1  0.5  10.2  0.4  1.9  0.4  0.6 
15–44  21.1  16.6  7.9  5.1  13.4  35.7  16.9  10.7  9.7  11.6 
45–64  42.1  30.1  33.9  20.8  57.1  30.6  30.1  28.6  23  31.4 
65–74  21.3  25.8  30.8  27.3  16.3  15.3  25.5  25.7  26.2  25.9 
>75  14.9  26.4  27.4  46.7  12.7  8.2  27.2  33  40.7  30.5 
Total  100  100  100  100  100  100  100  100  100  100 

DM: diabetes mellitus; HDs: hereditary diseases; PRD: primary renal disease; SDs: systemic diseases; GN: glomerulonephritis; VHN: vascular and/or hypertensive nephropathy; CPN/CIN: chronic pyelonephritis/chronic interstitial nephropathy; PKD: polycystic kidney disease; UO: unknown origin.

Fig. 3.

Distribution by age group of PRD in the patients who started RRT in 2013.

(0.24MB).
Fig. 4.

PRD by age group 2013.

(0.24MB).

The evolution of the overall incidence from 2007 to 2013 shows a sustained a gradual decrease from 127.4PMP in 2007 (in 2006 it was 130.6PMP) down to 120.4PMP in 2012, with a rise of 5.5%, up to 127.1, in 2013, which may be explained by an increase in incidence in the most populared ARs: Andalusia (5.2%), Catalonia (24.6%) and Madrid (14.8%), while in Valencia, the fourth most populated, it decreased (−5.2%) (Table 7 and Fig. 5).

Table 7.

Overall incidence, unadjusted rate 2007 to 2013 (PMP).

  2007  2008  2009  2010  2011  2012  2013  Variation 2012–2013 (%) 
Andalusia  117.9  125.6  118.8  116.6  114  117.5  123.6  5.2 
Aragon  131.9  109.3  118.9  121  121.1  131.2  124.7  −4.9 
Asturias  132.1  123.1  129.9    141.5  125.3  158.2  26.3 
Balearic Islands  111.3  125.4  95  79.6  103.1  144.7  141.5  −2.2 
Canary Islands  147.1  150.8  165.4  142.1  166.9  144     
Cantabria  92.5  120.2  125.6  140.1  116.3  114.5  106.4  −7 
Castile and León  124.2  124.7  120.1  116  115.7  123.3  107.1  −13.1 
Castile-La Mancha  102.7  99.8  95.6  104.4  94.5  98  102.3  4.4 
Catalonia  137.3  134.4  142.5  127.1  129.4  116.4  145  24.6 
Autonomous Community of Valencia  146  128.6  138.4  137.3  129.8  141  133.6  −5.2 
Extremadura  105.5  133  107.9  134.6  105.5  120  124.1  3.4 
Galicia  139.2  147.3  124.5  135.1  141.7  132.3  142.1  7.4 
Madrid  117.6  125  114.3  107.6  106.2  104.6  120.1  14.8 
Murcia          108.8  108.5  108.7  0.2 
Navarra  146.9  132.2  122.1  125.6  119.9  103.9  107.1 
Basque Country  113  107.6  126.1  105.1  107.1  111.7  119.5 
La Rioja  106.8  132.3  143  124.1  139.3  132.9  114.9  −13.5 
Ceuta  326.4  336  266.9  211  194.2  142.8  142.6  −0.2 
Melilla  331.2  279.9  122.5  118.4  140.2  210.4  95.6  −54.6 
Total in Spain  127.4  128.1  126.5  121.1  120.7  120.4  127  5.5 

PMP: patients per million of the population.

Fig. 5.

Evolution of incidence (PMP) overall and according to initial RRT modality. 2007–2013.

(0.21MB).

The decrease in incidence occurred at the expense of HD as an initial RRT, while the incidence of PD and early kidney transplant progressively increased reaching 21.5PMP and 5.5PMP, respectively in 2013 (Table 8 and Fig. 5).

Table 8.

Evolution of the percentage of the different initial RRT modalities 2007–2013.

  2007200820092010201120122013
  HD (%)  PD (%)  ETX (%)  HD (%)  PD (%)  ETX (%)  HD (%)  PD (%)  ETX (%)  HD (%)  PD (%)  ETX (%)  HD (%)  PD (%)  ETX (%)  HD (%)  PD (%)  ETX (%)  HD (%)  PD (%)  ETX (%) 
Andalusia  89.2  10.1  0.7  88.3  10.1  1.7  86.4  11.4  2.2  89.1  8.3  2.6  86  11.7  2.3  81.9  14.7  3.4  81  15.3  3.6 
Aragon  94.7  4.1  1.2  93.8  6.2  93.1  6.9  87.7  11  1.2  84  13.5  2.5  84.7  12.4  2.8  80.4  17.9  1.8 
Asturias  82.4  15.5  2.1  85  12  85.1  14.9  81.8  13.9  4.4  79.7  17  3.3  75.6  23.7  0.7  74  24.9  1.2 
Balearic Islands  88.7  11.3  90%  10%  0%  91.2%  8.8%  0%  89.8%  8%  2.3%  81%  18.1%  1%  80.2%  14.8%  4.9%  85.4%  6.9%  7.6% 
Canary Islands  88.6  11.1  0.3  88.2  11.8  86.5  13.5  84.1  15.9  87.6  12.4  84.3  15.7       
Cantabria  66  20.8  13.2  81.4  14.3  4.3  64.9  28.4  6.8  63.9  25.3  10.8  63.8  24.6  11.6  73.5  19.1  7.4  60.3  22.2  17.5 
Castile and León  86.6  13.1  0.3  82.8  17.2  79.5  20.5  79.8  18.5  1.7  78.4  20.3  1.4  80.6  18.5  81.5  16.3  2.2 
Castile-La Mancha  86.2  12.3  1.5  86.8  12.3  89.4  9.5  84.5  15.1  0.5  80.5  18.5  81.7  18.3  75.8  23.7  0.5 
Catalonia  86.5  9.3  4.2  84.5  10.6  4.8  81.4  11.5  81.4  12.4  6.3  81.9  12.1  75.7  16.3  7.9  79.7  13.1  7.2 
Autonomous Community of Valencia  91.3  7.9  0.8  91.5  7.3  0.8  90.1  7.9  85.2  11.7  3.4  83.9  15.2  0.9  79.4  17.3  3.3  78.6  20.6  0.7 
Extremadura  90.4  9.6  84.2  15.8  84.9  15.1  88.6  11.4  84.6  15.4  87.2  12.8  86.1  13.1  0.7 
Galicia  78.5  20.2  1.3  81.2  17.8  84.5  14.1  1.4  73.3  24.1  2.6  77.3  20.2  2.5  73.1  23.4  3.5  74  21.1  4.8 
Madrid  83.6  13.7  2.7  83.7  14.9  1.4  82.9  14.2  2.9  82.9  14.7  2.4  81.9  14.5  3.6  81.6  13.8  4.6  80.8  14.1  5.1 
Murcia                          85.6  13.1  1.3  86.9  11.3  1.9  78.1  20.6  1.3 
Navarra  89.9  10.1  84.1  15.9  85.7  14.3  91.3  11.3  76.6  18.2  5.2  76.1  19.4  4.5  76.8  21.7  1.4 
Basque Country  74  26  81  17.2  1.7  78.1  21.2  0.7  82.1  17.5  0.4  75.2  24.4  0.4  79.2  20  0.8  67.9  25.2  6.9 
La Rioja  81.8  18.2  85.7  14.3  100  37.5  32.5  80  20  79.1  20.9  75.7  21.6  2.7 
Ceuta  100  100  100  100%  100  100  100 
Melilla  100  100  100  0%  100%  0%  54.5  45.5  88.2  11.8  100 
Total in Spain  86.4  11.9  1.7  86.1  12.1  1.7  84.8  12.7  2.6  83.3  13.7  2.9  82.2  15.1  2.7  80  16.5  3.5  78.9  16.9  4.2 

PD: peritoneal dialysis (all modalities); HD: haemodialysis (all modalities); RRT: renal replacement treatment; ETX: early kidney transplant.

The PRD has been fairly stable. DM increased from 2007 to 2010, and it became the leading cause of RRT above UOs, then it became stable around 24.5–25% of incident patients (Fig. 6). On the other the incidence in PMP of DM continued to increase every year. It should be taken into consideration that in the last year, the data from the Canary Islands with a incidence of DM as a PRD much greater than the rest of the ARs, was not included in the analysis (Fig. 7).

Fig. 6.

Evolution from 2007 to 2013 of the percentage incidence of PRD.

(0.21MB).
Fig. 7.

Evolution of the incidence of DM as PRD at the start of RRT 2007–2013.

(0.08MB).
Prevalence

On December 31st 2013 there were 50,567 patients on RRT corresponding to a 95.3% of the total registry; the unadjusted prevalence rate was 1125.7PMP with a wide range among ARs. The prevalence was less than 1000PMP in the Balearic Islands, Cantabria, Madrid, Ceuta and Melilla, and greater than 1200 in Catalonia, Valencia, Galicia and Murcia (Table 9). Among the 50,567 prevalent patients, 31,596 were men (62.5%) and 18,971 were women (37.5%); this represents a rate of 1430PMP in men and 831.2PMP in women (Table 9); in Spain for every woman in RRT, there were 1.67 men This ration is varies from 1.25 in Melilla to 2.27 in Cantabria. By age group, the greatest prevalence corresponded to the group from 65 to 74 years of age that reached 3038.1PMP (Table 10 and Fig. 8).

Table 9.

Prevalence by sex and initial renal replacement treatment modality in 2013.

  TotalGenderInitial treatment
        NPMPNPMP
  Population  N  PMP  Male  Female  Male  Female  CHD  HHD  CAPD  CPD  FTX  CHD  HHD  CAPD  CPD  FTX 
Andalusia  8,440,300  9193  1089.2  5575  3618  1336.7  847.4  4104  384  4696  486.2  1.1  45.5  556.4 
Aragon  1,347,150  1504  1116.4  972  532  1450.8  785.6  549  65  883  407.5  1.5  48.3  3.7  655.5 
Asturias  1,068,165  1209  1131.8  783  426  1531.3  765.1  430  51  62  666  402.6  47.7  58  623.5 
Balearic Islandsa  1,017,395  945  928.8  598  347  1178.3  680.5  460  45  440  452.1  44.2  432.5 
Cantabria  591,888  569  961.3  395  174  1368.5  573.8  174  29  357  294  3.4  49  11.8  603.2 
Castile and León  2,519,875  2634  1045.3  1731  903  1388.8  709.1  1051  100  67  1414  417.1  0.8  39.7  26.6  561.1 
Castile-La Mancha  2,100,998  2150  1023.3  1324  826  1252.6  791.2  811  80  44  1212  386  1.4  38.1  20.9  576.9 
Catalonia  7,553,650  9533  1262  5975  3558  1603.9  929.4  4017  210  193  5110  531.8  0.4  27.8  25.6  676.5 
Autonomous Community of Valencia  5,113,815  6295  1231  3889  2406  1534.4  932.8  3325  10  351  46  2563  650.2  68.6  501.2 
Extremadura  1,104,004  1194  1081.5  735  459  1341.1  825.6  580  50  23  533  525.4  7.2  45.3  20.8  482.2 
Galicia  2,765,940  3361  1215.1  2109  1252  1579.6  875  1473  193  88  1600  532.5  2.5  69.8  31.8  578.5 
Madrid  6,495,551  6490  999.1  3991  2499  1277.6  741.1  2492  15  267  84  3632  383.6  2.3  41.1  12.9  559.2 
Murcia  1,472,049  1767  1200.4  1111  656  1501.7  895.9  896  86  778  608.7  58.4  4.8  528.5 
Navarra  644,477  753  1168.4  519  234  1617.2  723.2  271  11  20  447  420.5  6.2  17.1  31  693.6 
Basque Country  2,191,682  2457  1121.1  1567  890  1466.2  792.6  741  164  28  1521  338.1  1.4  74.8  12.8  694 
La Rioja  322,027  369  1145.9  233  136  1454.8  840.2  145  17  196  450.3  6.2  27.9  52.8  608.6 
Ceutab  84,180  81  962.2  54  27  1254.1  656.6  81  962.2 
Melillab  83,679  63  752.9  35  28  813.6  688.6  63  752.9 
Total in Spain  44,916,825  50,567  1125.8  31,596  18,971  1430.1  831.2  21,658  75  1666  1120  26,048  482.2  1.7  37.1  24.9  579.9 

CPD: cycling peritoneal dialysis; CAPD: continuous ambulatory peritoneal dialysis; CHD: centre haemodialysis; HHD: home haemodialysis; N: total number of cases; PMP: patients per million of the population; FTX: functioning kidney transplant.

a

The population covered on the Balearic Islands excludes the population of the Island of Menorca, which did not provide any data.

b

The autonomous cities of Ceuta and Melilla provide care for patients from neighbouring Morocco.

Table 10.

Prevalence by age group in 2013 (PMP).

  0–14  15–44  45–64  65–74  >75 
Andalusia  34  455.9  1723.5  3090.4  2654.3 
Aragon  37.4  395.4  1644.5  2674.1  2474.9 
Asturias  51.7  412  1544.8  2348.7  2140.8 
Balearic Islands  241.6  1348.7  2968.3  3577.3 
Cantabria  431.6  1461.3  2543.2  1479.9 
Castile and León  363.3  1477.3  2374.9  1960.1 
Castile-La Mancha  3.1  373.1  1615.6  2984.7  2358.3 
Catalonia  58.1  447.9  1846.3  3586  3288.1 
Autonomous Community of Valencia  56.1  426.9  1726.7  3250.6  3409.2 
Extremadura  6.3  423.3  1737.9  2492  2181.5 
Galicia  27.5  471.7  1761.5  2855.2  2004.2 
Madrid  36.5  376.3  1524.3  2864.9  2734.7 
Murcia  34.6  421.5  1978.4  3606  3762.4 
Navarra  267.9  1324.4  3084.3  4692.8 
Basque Country  56.1  483.6  1524.7  2819.5  2134.9 
La Rioja  516.2  1525.2  3392.9  2382.6 
Ceuta  160.2  1837.5  4938.8  3150 
Melilla  372.9  1139.1  2338.6  4397.3 
Total in Spain  36.3  419.4  1669  3038.1  2712 

PMP: patients per million of the population.

Fig. 8.

Prevalence PMP by age group 2013.

(0.09MB).

The adjusted overall prevalence rate in 2013 was 1087.5PMP; 1360.7PMP in males and 809.8PMP in females (Table 11 and Fig. 9).

Table 11.

Age-adjusted prevalence (EU27, 2005) 2013 (PMP).

  Male  Female  Total 
Murcia  1600.8  971  1294.8 
Catalonia  1555.6  917  1238.4 
Ceuta  1568.5  838.1  1218.9 
Autonomous Community of Valencia  1439  902.9  1177.6 
Andalusia  1351.1  874  1113.9 
La Rioja  1351.8  812  1091 
Navarra  1455.8  678.1  1081.9 
Galicia  1342.7  777.7  1058.6 
Aragon  1291.5  726.5  1017.5 
Madrid  1298.1  752.8  1016 
Basque Country  1299.2  732.1  1015.1 
Castile-La Mancha  1217.5  793.5  1014.9 
Extremadura  1231  779.7  1011.2 
Melilla  1004.9  956.8  989 
Balearic Islands  1218.6  726.3  982.2 
Asturias  1256.4  649.5  946.8 
Cantabria  1241.6  547  893.6 
Castile and León  1146.5  615.1  889.7 
Total  1360.7  809.8  1087.5 

PMP: patients per million of the population.

Fig. 9.

Age-adjusted prevalence 2013.

(0.22MB).

At the end of the year 2013 on 31 December 2013, 26,043 prevalent patients had a functioning kidney transplant (51.5%), while 21,656 (42.8%) received treatment in HD centers, 78 (0.15%) were on home HD; 1667 (3.3%) received continuous ambulatory peritoneal dialysis and 1120 (2.2%) received cycling PD (Table 9).

Regarding PRD in the prevalent patients, glomerulonephritis was the most common with 20.4% and 231PMP, followed by UO (20.3% and 229PMP) and DM (14.9% and 168PMP), although with marked differences among ARs (Figs. 10 and 11).

Fig. 10.

DM as PRD in prevalent patients in RRT PMP, according to AR 2013.

(0.16MB).
Fig. 11.

Percentage of DM among prevalent patients in RRT, according to AR 2013.

(0.17MB).

On December 31st 2013 among RRT patients on HD and PD in all their varieties, there were 1.8% with positive serology for hepatitis B surface antigen (HBV+), 6.9% were positive for the hepatitis C virus (HCV+) and 1.3% had positive serology for the human immunodeficiency virus (HIV+).

The overall prevalence in Spain show a progressive increase with values above 1000PMP since 2009 reaching 1125.8PMP in 2013 (Table 12 and Fig. 12). This increase, although it also occurred in patients in HD, was markedly reflected in patients with PD, and above all in transplant patients, who exceeded 50% starting in 2012 (Table 13 and Fig. 12).

Table 12.

Overall prevalence, unadjusted rate PMP 2007 to 2013 (PMP).

  2007  2008  2009  2010  2011  2012  2013 
Andalusia  952.9  960.3  977.4  1004.1  1028.4  1054.1  1089.2 
Aragon  789.7  950.3  998.2  994.7  1028.8  1071.5  1116.4 
Asturias  1077.3  973.9  990.5    1030.1  1069.3  1131.8 
Balearic Islands  496.9  434.2  588.1  792  886.8  877.2  928.8 
Canary Islands  994.6  607.4  1169.2  1143.3  680.4  1162.7   
Cantabria  844.9  834.9  874  883.1  891.9  931.2  961.3 
Castile and León  935.8  965.5  994.3  1010.7  1014.7  1038.9  1045.3 
Castile-La Mancha  927  911.4  929.2  964.6  997.5  1004.3  1023.3 
Catalonia  1099.1  1123.7  1158.5  1188.4  1222.9  1200.1  1262 
Autonomous Community of Valencia  1103.8  1098.9  1107.2  1130.9  1147.3  1195.1  1231 
Extremadura  893.6  920.1  952.5  999.8  1026.7  1049.5  1081.5 
Galicia  1047.8  1061.4  1079  1125.9  1171.6  1178.1  1215.1 
Madrid  971.6  1077.2  907.8  926.7  956.6  970.1  999.1 
Murcia          1117.6  1153  1200.4 
Navarra  485.2  486.8  472.6  500.8  1151  1137.2  1168.4 
Basque Country  959.9  1016.6  1024.8  1019.6  1055.6  1093  1121.1 
La Rioja  987.2  1124.4  1038.2  1045.2  1136.4  1072.3  1145.9 
Ceuta  900.7  969.1  1004.1  1092.1  1031.9  1023.6  962.2 
Melilla  1022.5  1007.7  803.2  789.1  828.3  841.6  752.9 
Total in Spain  985.3  994.8  1015.7  1036.7  1054.6  1091.1  1125.8 

PMP: patients per million of the population.

Fig. 12.

Evolution of prevalence (PMP) overall and according to RRT modality 2007–2013.

(0.21MB).
Table 13.

Evolution of the percentage of the different RRT modalities in prevalent patients 2007–2013.

  2007200820092010201120122013
  HD (%)  PD (%)  TX (%)  HD (%)  PD (%)  TX (%)  HD (%)  PD (%)  TX (%)  HD (%)  PD (%)  TX (%)  HD (%)  PD (%)  TX (%)  HD (%)  PD (%)  TX (%)  HD (%)  PD (%)  TX (%) 
Andalusia  48.6  4.5  46.9  48.9  4.1  47  48.2  4.3  47.5  47.7  4.3  47.9  46.1  4.3  49.6  45.1  4.4  50.5  44.7  4.2  51.1 
Aragon  50.5  0.8  61.8  42  1.1  56.9  44.7  1.5  53.8  44.3  2.8  53  40.2  3.7  56.1  39.3  4.3  56.4  36.6  4.7  58.7 
Asturias  32.7  4.5  51.2  37.4  5.4  57.2  37.3  5.7  57  37.7  5.8  56.5  37.4  5.9  56.6  35.7  55.3  35.6  9.3  55.1 
Balearic Islands  91.5  8.5    91    92.6  7.4    47.1  3.8  49.1  44.7  4.5  50.7  47.9  4.9  47.3  48.7  4.8   
Canary Islands  54.4  4.4  41.1  91.8  8.2  72.7  50.5  44.5  51.6  5.8  42.6  89.7  10.3    49.2  5.3  45.4       
Cantabria  36.4  9.5  54.1  38.3  54.7  37.5  7.4  55.1  34.4  7.5  58.1  32.5  7.6  59.9  32.5  6.7  60.8  30.9  6.3  62.7 
Castile and León  45.4  5.5  49.1  44.8  5.9  49.3  43.9  6.5  49.6  42.8  6.5  50.7  42  51  41.1  6.5  52.5  40  6.3  53.7 
Castile-La Mancha  43  5.2  51.8  41.5  3.9  54.7  41.3  3.8  55  41.3  4.5  54.2  41%  5.1  53.9  39.2  5.7  55.1  37.9  5.8  56.4 
Catalonia  46.4  3.5  50.1  46.2  3.6  50.2  45.3  3.7  51  44.5  51.5  42.7  3.9  53.4  41  4.1  54.9  42.2  4.2  53.6 
Autonomous Community of Valencia  56.5  4.3  39.2  56.7  3.8  39.3  56  3.5  40.5  56.2  3.4  40.3  55.2  4.9  39.8  54.6  5.5  40  53  6.3  40.7 
Extremadura  49  5.9  45.2  48.6  45.3  48.9  6.2  45  50.6  5.9  43.5  49.3  5.8  45  49.2  6.4  44.5  49.3  6.2  44.5 
Galicia  43.3  9.2  47.5  45.8  9.4  44.8  46.1  8.6  45.3  45.8  8.8  45.4  45  8.7  46.3  44.6  8.2  47.2  44  8.4  47.6 
Madrid  35.5  7.3  57.2  36.4  5.1  58.4  41.4  5.9  52.7  40.4  5.7  53.9  39  5.5  55.5  38.5  5.6  56  38.6  5.4  56 
Murcia                          55.6  40.4  53.5  4.3  42.2  50.7  5.3  44 
Navarra  89.5  10.5  111.2  90.4  11.3  117.9  78.2  12.8  89  11.3  123.2  37.8  5.1  57.1  37.1  4.8  58.1  36.5  4.1  59.4 
Basque Country  30  8.3  61.7  31.5  7.7  60.8  29.6  7.8  62.6  31.5  8.1  60.4  31.5  8.7  59.8  31.2  8.2  60.6  30.3  7.8  61.9 
La Rioja  37.7  4.9  57.4  37.3  4.5  51.3  44.9  3.3  51.8  41.2  55.8  39.5  6.8  53.7  42.9  8.6  48.4  39.8  53.1 
Ceuta  100    100    100    100    100    100    100   
Melilla  100    97.2    100    100    96.9  3.1    97.1  2.9    100   
Total in Spain  46.2  5.3  49.3  47.1  5  50.8  46.5  5  48.5  46  5.1  49.8  45.6  5.4  49  43.7  5.4  50.9  43  5.5  51.5 

PD: peritoneal dialysis; HD: haemodialysis; RRT: renal replacement treatment; TX: transplant.

Kidney transplant

In Spain, during 2013, there were 2552 kidney transplants performed in Spain, with a rate of 47.12PMP. Based on donor type, 382 (14.97%) were from a living donor and 200 (7.8%) were from a donor who was deceased by circulatory and respiratory criteria (asystole). In 67 cases the transplant recipient was a child under 16 years of age (Table 14).

Table 14.

Kidney transplants by AR of the transplant centre. 2013.

AR/HOSPITAL  Total in 2013  Chi  Asyst  Living  DK  EB 
Andalusia  412  11  32  60   
Aragon  85      11     
Asturias  48       
Balearic Islands  39           
Canary Islands  101    12     
Cantabria  61       
Castile-La Mancha  94     
Castile and León  108       
Catalonia  540  21  25  165 
Autonomous Community of Valencia  237  13   
Extremadura  30           
Galicia  132    28     
La Rioja  16         
Madrid  406  19  104  40   
Murcia  61         
Navarra  26         
Basque Country  156  38     
Total in Spain  2552  67  200  382  9  5 

Asyst: transplant from a deceased donor in asystole; EB: en bloc double kidney transplant from a child donor; DK: double kidney transplant and older donor; AR: autonomous region; Chi: transplant in children under 15 years of age; Living: transplant from a living donor.

From 2007 to 2013, the number of kidney transplants increased by 15.4%, and the rate PMP increased by more than 5 points, from 48.9PMP to 54.2PMP. This increase is mostly due to the increase in donations by living donors and in the use of organs from deceased donors in asystole (Table 15 and Fig. 13).

Table 15.

Kidney transplants overall and by AR 2007–2013.

Autonomous region  2007  2008  2009  2010  2011  2012  2013 
Andalusia  344  367  381  330  426  457  412 
Aragon  63  55  66  65  74  68  85 
Asturias  54  40  46  43  53  50  48 
Balearic Islands  28  46  45  43  43  52  39 
Canary Islands  145  126  103  104  116  91  101 
Cantabria  41  27  46  42  48  36  61 
Castile-La Mancha  36  51  51  54  59  55  94 
Castile and León  83  86  79  93  85  117  108 
Catalonia  470  471  524  460  581  559  540 
Autonomous Community of Valencia  231  198  209  209  190  232  237 
Extremadura  30  35  33  32  44  34  30 
Galicia  96  120  127  131  146  138  132 
La Rioja          10  16 
Madrid  395  407  417  420  406  432  406 
Murcia  52  45  48  47  54  76  61 
Navarra  18  26  35  25  40  32  26 
Basque Country  125  129  118  127  123  117  156 
Total in Spain  2211  2229  2328  2225  2498  2551  2552 
Total in Spain (PMP)  48.92  48.29  49.80  47.32  52.93  53.97  54.15 
Living donor transplants  137  156  235  240  312  361  382 
Transplants from a donor in asystole  104  105  145  158  140  201  200 
Transplants in Children  72  62  62  58  63  59  67 

AR: autonomous region; PMP: patients per million of the population.

Fig. 13.

Evolution of the number of transplants according to donor type. BD: brain death.

(0.2MB).

The percentage of transplant patients that returned to dialysis (HD or PD) due to transplant failure remained stable at around 2.5% (Fig. 14).

Fig. 14.

Percentage of patients who returned to dialysis following kidney transplant failure.

(0.07MB).
Mortality

The overall mortality of patients in RRT remained stable around 8% annually throughout the period 2007–2013. Mortality remain stable in the three modalities of RRT (HD, PD and transplant), although there was a very modest increase in mortality in transplant patients, which continues to be the lowest of the 3 modalities (Table 16).

Table 16.

Evolution of annual mortality 2007–2013, by treatment modality (%).

  2007  2008  2009  2010  2011  2012  2013 
Mortality in HD  15.27  14.52  14.79  14.60  14.12  14.43  15.1 
Mortality in PD  8.79  10.54  8.44  8.13  8.07  8.85  8.86 
Mortality in TX  1.64  1.50  1.89  1.67  1.85  2.31  2.35 
Overall  8.46  8.34  8.36  8.24  7.78  7.96  8.18 

PD: peritoneal dialysis; HD: haemodialysis; TX: transplant.

Survival

Between 2004 and 2012 there were 40,394 incident patients that met the selection criteria. Tables 17 and 18 show the distribution by AR and year.

Table 17.

Distribution by AR of the incident patients 2004–2012 included in the survival analysis.

Autonomous Region  2004–2012
N (%) 
Andalusia  8175 (20.2) 
Aragon  1478 (3.6) 
Asturias  1197 (3) 
Cantabria  575 (1.4) 
Castile-La Mancha  1943 (4.8) 
Castilla y León  2697 (6.7) 
Catalonia  8539 (21.1) 
Autonomous Community of Valencia  6119 (15.1) 
Extremadura  1113 (2.8) 
Galicia  3121 (7.1) 
Madrid  3298 (8.8) 
Basque Country  2159 (5.3) 
Total  40,394 (100) 

AR: autonomous region; N: number of cases.

Table 18.

Distribution by year of the incident patients 2004–2012 included in the survival analysis.

Year of inclusion  N (% compared to total) 
2004  4056 (10.0) 
2005  4093 (10.1) 
2006  4093 (10.1) 
2007  4204 (10.4) 
2008  4972 (12.3) 
2009  4938 (12.2) 
2010  4802 (11.9) 
2011  4664 (11.5) 
2012  4572 (11.3) 
Total  40,394 (100) 

N: number of cases.

Table 19 shows the main characteristics of the sample.

Table 19.

Characteristics of the patients included in the survival analysis 2004–2012.

Characteristics  N 
Sex
Male  25,858  64 
Female  14,536  36 
Age groups
Under 20  166  0.4 
20 to <45  5086  12.6 
45 to <65  12,826  31.8 
65 to <75  10,923  27 
75+  11,393  28.2 
Age at the start of treatmentMean: 64.06 (SD=15.16)   
Median: 67.28 (IQR: 54.54–75.94)   
Diabetes
Yes  8533  21.1 
Initial RRT
Haemodialysis  34,869  86.3 
Peritoneal dialysis  5515  13.7 
Transplant
Yes  7772  19.2 
Death  13,867  34.3 
Censure events
(loss to follow-up, recovery of renal function or transfer to another registry)  1212 
Total  40,394  100 

SD: standard deviation; N: number of cases; IQR: interquartile range; RRT: renal replacement treatment.

Estimated median survival was 6.2 years, with a 95% confidence interval of 6.1 and 6.4.

The unadjusted probability of survival was 91%, 81% and 57% after one, 2 and 5 years, respectively, as shown in Table 20.

Table 20.

Unadjusted survival.

Years  N of events  N who entered in the interval  N at risk  Survival (%)  95% CI 
3422  40,394  37,936  91  90.8–91.2 
3319  32,057  29,930  81  80.6–81.4 
1250  12,980  11,500  57  56.6–57.4 

N: number of cases; 95% CI: 95% confidence interval.

Table 21 presents the adjusted survival analysis; those variables that had turned out to be significant in the univariate analysis were included as potential predictive factors.

Table 21.

Cox model.

Variable  HR  95% CI  p 
Age group
15–19 years  0.47  0.20–1.14  0.96 
20–44 years  –  0.000 
45–64 years  2.7  2.41–2.99  0.000 
65–74 years  4.44  3.99–4.93  0.000 
≥75 years  6.35  5.71–7.06  0.000 
Diabetes as PRD  1.28  1.23–1.33  0.000 
Female sex  0.86  0.83–0.90  0.000 
PD as initial RRT  0.91  0.85–0.96  0.001 
Transplant  0.16  0.15–0.18  0.000 

PD: peritoneal dialysis; PRD: primary renal disease; HR: hazard ratio; 95% CI: 95% confidence interval; RRT: renal replacement treatment.

The Cox model shows the following as independent factors of survival: age, diabetes as PRD, transplanted, sex and modality of initial RRT (Table 21), survival being worse for diabetic men over 45 years of age who had started RRT with HD and who had not undergone a transplant.

Fig. 15 shows the survival curves for the incident patients during the period 2004–2012 based on age group.

Fig. 15.

Survival of incident patients in the period 2004–2012 for the different age groups.

(0.14MB).
Discussion and conclusions

Over the course of these 7 years, the REER was able to collect and assemble information about a percentage above 95% of the population of Spain reaching 100% in 2012, this is despite the occasional difficulties of some of the autonomous region registries. Therefore, the future objective should be to cover 100% of the population every year, with a tendency to group individualised data from an ever greater number of registries, until a total coverage throughout Spain is achieved. Likewise, the quality of data collected is improved, as demonstrated by the temporal coherence of the data.

Annual incidence sustained a gradual decrease, although in 2013 we observed a rise that will have to be confirmed as a result of either a change in the trend or simply a temporary isolated increase. The evolution of incidence in the different varieties of RRT showed the marked decrease in HD as an initial treatment, which went from 86.4% in 2007 to 78.9% in 2013, while the percentage of patients who started RRT with PD increased from 11.9% in 2007 to 16.9% in 2013, and those who had undergone a transplant without previous treatment with HD or PD increased from 1.7% in 2007 to 4.2% in 2013.

The total number of prevalent patients with ESRD in RRT grew from one year to the next, and exceeded 1000PMP in 2010, essentially owing to an increase in functioning kidney transplants, which represented 49.3% in 2007 and 51.5% in 2013.

International comparisons

Comparisons were made with countries with international registries available when the present manuscript was written. The latest USRDS report20 included data on 2012 and the evolution of the epidemiological data for ESRD from 2006 to 2012.

Incidence

The incidence rate of the countries whose data were collected by the USRDS in 2012 ranged from 25PMP in Ukraine to 450 in Taiwan and 467 in Jalisco (Mexico). Spain (121PMP) was in the below the middle of the table, with numbers similar to those of western European countries with similar characteristics (Fig. 16). In these seven years there was a 3.1% decrease, in the same range that Australia (−3.1%), Canada (−4.5%), the Netherlands (−3.3%), Norway (−3.9%) and Israel (−3.9%). Some European countries experienced an even more marked decrease in incidence: Austria (−10.3%), Czech Republic (−7.2%), Denmark (−9.7%), Finland (−7.6%) and Sweden (−7.9%) (Fig. 17).

Fig. 16.

Unadjusted incidence rate (PMP) by country in 2012.

(0.28MB).
Source: United States Renal Data System, 2014 Annual Data Report: Epidemiology of Kidney Disease in the United States. 2014. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases (2014). Special analyses, USRDS ESRD Database. Data presented only for countries from which relevant information was available. All rates are unadjusted. ^UK: England, Wales and Northern Ireland (Scotland data reported separately). Japan and Taiwan are dialysis only. Data for Belgium do not include patients younger than 20. Data for Indonesia represent the West Java region. Data for France include 22 regions. Data for Spain include 18 of 19 regions.
Fig. 17.

Evolution of the ESRD incidence rate (PMP) by country, 2000 to 2012, in countries whose incidence rate decreased by at least 3% from 2006 to 2012.

(0.18MB).
Source: United States Renal Data System, 2014 Annual Data Report: Epidemiology of Kidney Disease in the United States. 2014. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases (2014). Special analyses, USRDS ESRD Database. All rates are unadjusted. Data are shown for countries with incidence increase or decrease from 2006 to 2012 or 2011.

The percentage of DM as PRD varied widely among countries (Fig. 18), with the highest rates in Singapore (66%), Malaysia (61%) and Jalisco (Mexico) (59%), while it represented less than 20% in Flemish Belgium, Russia, Norway, the Netherlands, Romania and Ukraine.

Fig. 18.

Percentage of incident patients with ESRD, in whom diabetes mellitus was the primary renal disease, by country, in 2012.

(0.28MB).
Source: United States Renal Data System, 2014 Annual Data Report: Epidemiology of Kidney Disease in the United States. 2014. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases (2014). Special analyses, USRDS ESRD Database. Data presented only for countries from which relevant information was available. ^UK: England, Wales and Northern Ireland (Scotland data reported separately). Data for Spain include 18 of 19 regions. Data for France include 22 regions. Data for Indonesia represent the West Java region. Data for Belgium do not include patients younger than 20. There were zero ESRD patients in Iceland with diabetes as the primary ESRD cause in 2012. Abbreviations: ESRD: end-stage renal disease; sp.: speaking.
Prevalence

The prevalence at December 31st 2012 was 2902PMP in Taiwan, 2365PMP in Japan and 1976PMP in United States, while in Bahrain, Qatar, Indonesia, Russia, South Africa and Ukraine less than 300PMP received RRT; Spain, with 1091, was in the upper third of the table In the majority of western European countries the range was between 808PMP in Finland to 1670PMP in Portugal (Fig. 19). From 2006 to 2012 Spain unadjusted prevalence increased by 12.9%, similar to the countries around i (Fig. 20), although the prevalence of treatment with dialysis has decreased by 0.4% with the consequent increase in the numbers of transplanted patients and with a functioning graft.

Fig. 19.

Prevalence of ESRD in RRT, PMP by country, in 2012.

(0.31MB).
Source: United States Renal Data System, 2014 Annual Data Report: Epidemiology of Kidney Disease in the United States. 2014. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases (2014). Special analyses, USRDS ESRD Database. Data presented only for countries from which relevant information was available. All rates are unadjusted and reflect prevalence at the end of 2012; rates for Colombia and Lebanon reflect prevalence at the end of June 2012. ^UK: England, Wales and Northern Ireland (Scotland data reported separately). Japan and Taiwan include dialysis patients only. Data for Belgium do not include patients younger than 20. Data for Indonesia represent the West Java region. Data for Spain include 18 of 19 regions. Data for France include 22 regions. Data for Turkey in 2012 was collected with the collaboration of the Ministry of Health, which collects patient-based data; however, in previous years center-based data were reported. Abbreviations: ESRD: end-stage renal disease; sp.: speaking.
Fig. 20.

Trend in the prevalence of ESRD in RRT, PMP by country, in 2012.

(0.33MB).
Source: United States Renal Data System, 2014 Annual Data Report: Epidemiology of Kidney Disease in the United States. 2014. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases (2014).
Transplants

In accordance with the 2014 USRDS report,20 there was major variability in transplant rates among reporting countries, which did not only reflect the variations in incidence and prevalence reported. The highest transplant rate reported, 60PMP in Norway, was 30 times higher than the lowest transplant rate reported, 2PMP in Ukraine. The highest rates of kidney transplant for all donor types were those reported by Norway (60PMP), Jalisco (Mexico) (59PMP), the Netherlands (57PMP), the United States (55PMP), Croatia (54PMP) and Spain (54PMP) (Fig. 21): Although, according to the data of the Global Observatory on Donation and Transplantation (GODT),21 the highest rate of kidney transplant from a deceased donor is 50.5PMP in Croatia followed by Spain (46.8PMP), Belgium (44.4PMP), Estonia (43.9PMP) and Norway (43.6PMP) (Fig. 22).

Fig. 21.

Rate of kidney transplant, PMP, by country, in 2012.

(0.33MB).
Source: United States Renal Data System, 2014 Annual Data Report: Epidemiology of Kidney Disease in the United States. 2014. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases (2014). Special analyses, USRDS ESRD Database. Data presented only for countries from which relevant information was available. All rates are unadjusted. ^UK: England, Wales and Northern Ireland (Scotland data reported separately). Data for Belgium do not include patients younger than 20. Data for France include 22 regions. Data for Spain include all regions. There is underreporting of prevalent transplant patients in Turkey. Abbreviations: sp.: speaking.
Fig. 22.

Rate of kidney transplant, PMP, by country, in 2013, according to donor type. DD: deceased donor; LD: living donor.

(0.66MB).
Source: Global Observatory on Donation and Transplantation (GODT). Organ Donation and Transplantation Activities 2012.

The evolution of the annual rate of transplants from 2006 to 2012 showed an increase in the overall rate in countries of the European Union and all countries of the World Health Organization that reported to the GODT21 (Table 22). The increase observed in Spain is comparatively much higher, with an 18.3% increase in total kidney transplants, with the extraordinary contribution of transplants from a living donor (253.9%) and from deceased donors in asystole (107.2%).

Table 22.

Evolution of kidney transplants 2006–2012.

  EU27UE28  % increase 2006–2012 
  2006  2007  2008  2009  2010  2011  2012   
Population  488.42  492.3  493  500  501.6  504.2  507.5  3.9 
Total kidney TXs  16,819  17,306  17,198  17,886  18,246  18,712  19,085  13.5 
TX from living donor  2617  2926  3089  3354  3616  3857  3970  51.7 
TX from deceased donor  14,204  14,380  14,109  14,532  14,630  14,855  15,115  6.4 
TX from donor in asystole  598  707  837  1007  1037  1178  1400  134.1 
Total TXs PMP  34.4  35.2  34.9  35.8  36.4  37.1  37.6  9.2 
Living donor TX PMP  5.4  5.9  6.3  6.7  7.2  7.6  7.8  46 
TX from deceased donor PMP  29.1  29.2  28.6  29.1  29.2  29.5  29.8  2.4 
TX from donor in asystole PMP  1.2  1.4  1.7  2.1  2.3  2.8  125.3 
  Spain
Population  44.7  45.2  46.2  46.75  47  47.2  46.8  4.7 
Total kidney TXs  2157  2211  2229  2328  2225  2498  2551  18.3 
TX from living donor  102  137  156  235  240  312  361  253.9 
TX from deceased donor  2055  2074  2073  2093  1985  2186  2190  6.6 
TX from donor in asystole  97  104  105  148  158  140  201  107.2 
Total TXs PMP  48.3  48.9  48.2  49.8  47.3  52.9  54.5  13 
Living donor TX PMP  2.3  3.4  5.1  6.6  7.7  238 
TX from deceased donor PMP  46  45.9  44.9  44.8  42.2  46.3  46.8  1.8 
TX from donor in asystole PMP  2.2  2.3  2.3  3.2  3.4  4.3  97.9 
  103 Member countries of the World Health Organization that provided data to the GODT
Total kidney TXs  65,700  65,511  68,250  69,214  71,418  73,179  76,118  15.9 

GODT: Global Observatory on Donation and Transplantation; PMP: patients per million of the population; TX: transplant.

Survival

Comparisons with international data20,22 with respect to the survival of patients in RRT were limited by differences in the methodology used for analysis and data processing as well as differences in the analysis of cohorts followed through different periods of time.

Conflicts of interest

The author has no conflicts of interest to declare.

Annex 1
REER members

Spanish Transplant Organisation: Eduardo Martín-Escobar, Beatriz Mahillo Durán; Spanish Society of Nephrology (SEN): J. Emilio Sánchez, Ramón Saracho Rotaeche; Andalusia Renal Registry (SICATA): Pablo Castro de la Nuez, Miguel Ángel Gentil Govantes; Aragon Renal Registry: José M. Abad Diez, José Ignacio Sánchez Miret; Asturias Renal Registry: Ramón Alonso de la Torre, José Ramón Quirós García; Balearic Islands Renal Registry: Catalina Garrigó; Valencia Renal Registry (REMRENAL): Manuel Ferrer-Alamar, Oscar Zurriaga Llorens; Cantabria Renal Registry: Manuel Arias, Óscar García Ruiz; Castilla-La Mancha Renal Registry: Gonzalo Gutierrez Ávila, Inmaculada Moreno Alía; Castilla y León Renal Registry: Raquel Gonzalez Fernández, José María Monfá Bosch; Catalonia Renal Registry: Jordi Comas Farnes, Emma Arcos Fuster; Extremadura Renal Registry: María A. García Bazaga, Julian Mauro Ramos Aceitero; Galicia Renal Registry: Encarnación Bouzas Caamaño, Teresa García Falcón, Jacinto Sánchez Ibañez; La Rioja Renal Registry: Enma Huarte-Loza, Marta Artamendi Larrañaga; Madrid Renal Registry (REMER): Manuel Aparicio Madre, José A. Herrero; Murcia Renal Registry: Carmen Santiuste de Pablos; Navarra Renal Registry: Jesús Arteaga Coloma; Basque Country Renal Registry: Angela Magaz Lago, Iñigo Moina Eguren.

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Please cite this article as: Martín Escobar E. Registro Español de Enfermos Renales. Informe 2013 y evolución 2007-2013. Nefrologia. 2016;36:97–120.

The names of the components of the Registro Español de Enfermos Renales (REER) are listed in Annex 1.

Copyright © 2015. Sociedad Española de Nefrología
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