• •

  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.

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  Donation and transplant registry of the Spanish Transplant Organisation.

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  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.

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  2007–2013 for prevalence, incidence and transplants.

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  2004–2012 for the survival analysis.

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

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

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  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).

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).

Fig. 1.

Age-adjusted incidence 2013.

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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.

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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).

Fig. 3.

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

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Fig. 4.

PRD by age group 2013.

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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).

Fig. 5.

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

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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).

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.

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Fig. 7.

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

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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).

Fig. 8.

Prevalence PMP by age group 2013.

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

Fig. 9.

Age-adjusted prevalence 2013.

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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.

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Fig. 11.

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

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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).

Fig. 12.

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

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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).

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).

Fig. 13.

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

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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.

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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).

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 19 shows the main characteristics of the sample.

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 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.

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.

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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.

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.

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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.

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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.

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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.

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.

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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.

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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).

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.

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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.

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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%).

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.