RENAL REPLACEMENT THERAPY IN BOSNIA AND HERZEGOVINA IN 2017

Halima Resic, MD, PhD - Clinic for haemodialysis, Clinical Center University of Sarajevo Besim Prnjavorac, MD, PhD – Hospital Tesanj

Zahvalnost Kolegama iz centara za dijalizu i transplantaciju na učešću u prikupljanju

podataka za Renalni registar Bosne i Hercegovine

2

Banja Luka, Aleksandar Arezina

Bihac, Mirjana Mujakic

Bijeljina, Ljiljana Lukic

Brcko District, Vera Marincic

Doboj, Gordana Zole

Foca, Marijana Kovacevic

Gradiska, Dejan Daljevic

Gracanica, Nermin Slamnik

East Sarajevo, Olivera Seslija

Konjic, Indira Spanja

Laktasi, Biljana Jakovljevic

Livno, Zdenka Kelava

Mostar, Slavica Coric

Orasje - Odzak, Zelimir Stipancic

Prijedor, Ljubomir Vukovic

Samac, Nenad Petkovic

Sarajevo - Clinic for haemodialisys, Halima Resic

Sarajevo - Clinic for nephrology, Senija Rasic

Sarajevo, Pediatric Clinic, Danka Pokrajac

Sarajevo – Ilidza, Emir Avdic

Tesanj, Besim Prnjavorac

Travnik, Dzemil Hrnjic

Trebinje, Branimir Cihoric

Tuzla, Enisa Mesic

Zenica, Lejla Hantalasevic Becic

Zvornik, Koviljka Bogicevic

Zivinice, Mersiha Cerkezovic

Centers for dialysis and transplantation in Bosnia and Herzegovina

3

Transplantaton

Centers inu BiH

Dialysis centers

with the highest

number of patients

with endemic

nephropathy

1257 patients

(41,5%)

Incidence

Prevalence

Primary renal disease

Treatments modality

Blood transmitted diseases

Vascular access

Acute renal failure

Outcome

4

Epidemiology HBB - Incidence

Incidence in B&H (at day 1) - comparasion Years 2002-2017

Incidence u B&H (at day 1)

Year 2002 Year 2017

N pmp N pmp

Federation B&H 252 * 228 102,7

R. Srpska 120 * 140 114,0

Distrikt Brcko 18 * 14 167,6

Bosnia & Herzegovina 390 101,8 382 108,2

5

* In 2002 there were no official data on the number of inhabitants by entities and Brcko DC.

6

Incidenc patients (at day 1) by age, by entity and Brcko DC, in year 2017

Year 2017 Age group Total

(N) 0-19 20-44 45-64 65-74 ≥75

Federation

B&H 3 (1,3%) 22 (9,6%) 100 (43,9%) 65 (28,5%) 38 (16,7%) 228

R. Srpska 1 (0,7%) 153 (10,7%) 51 (36,4%) 45 (32,1%) 28 (20,0%) 140

Distrikt Brcko 0 (0,0%) 3 (21,4%) 5 (35,7%) 5 (35,7%) 1 (7,1%) 14

Bosnia and

Herzegovina 4 (1,0%) 40 (10,5%) 156 (40,8%) 115 (30,1%) 67 (17,5%) 382

7

Incident patients (per day) in B&H, by age, by entities and Brcko DC in 2017 - graphical

1,3

(3 p

at.

)

9,6

(22 p

at.

)

43,9

(100 p

at.

)

28,5

(65 p

at.

)

16,7

(38 p

at.

)

0,7

(1 p

at.

)

10,7

(15 p

at.

)

36,4

(51 p

at.

)

32,1

(45 p

at.

)

20,0

(28 p

at.

)

0,0

(0 p

at.

)

21,4

(3 p

at.

)

35,7

(5 p

at.

)

35,7

(5 p

at.

)

7,1

(1 p

at.

)

0,0

5,0

10,0

15,0

20,0

25,0

30,0

35,0

40,0

45,0

0-1

9

20-4

4

45-6

4

65-7

4

75+

0-1

9

20-4

4

45-6

4

65-7

4

75+

0-1

9

20-4

4

45-6

4

65-7

4

75+

FBIH RS Brcko DC

Age group

%

8

Incidence in the last 5 years - graphical

108,2112,1

114,4

120,9

116

105,0

110,0

115,0

120,0

125,0

2013 2014 2015 2016 2017

Godina

Pm

p

9

Incidenc patients (at day 1) - abstract

Of 382 incident patients in 2017 (108,2 pmp), 231 patients vere man (133,4 pmp) and 151 woman (83,9 pmp).

Man make up 60,5% of all incidenc patients at day 1.

Average age of the 382 incidenc patients is 61,8

Incidence

Prevalence

Primary renal disease

Treatments modality

Blood transmitted diseases

Vascular access

Acute renal failure

Outcome

10

Renal failure epidemiology - Prevalence

Distribution of dialysis patients by age and gender at day 31.12.2017

Age group All Males Females

0-19 18 (0,7%) 11 (0,7%) 7 (0,7%)

20-44 453 (17,1%) 288 (18,0%) 165 (15,7%)

45-64 1111 (41,9%) 701 (43,8%) 410 (39,0%)

65-74 644 (24,3%) 374 (23,4%) 270 (25,7%)

75+ 427 (16,1%) 227 (14,2%) 200 (19,0%)

Total : 2653 1601 1052

Mediana 61,0 godina 60,0 godina 63,0 godina 11

12

Prevalent patients age group on the 31.12.2017 - graphical

0,7

%

17

,1%

41

,9%

24

,3%

16

,1%

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

Age group

13

Prevalence in the last 5 years - graphical

74

2,6

74

8,5

74

5,4 74

9,9

75

1,3

730,0

735,0

740,0

745,0

750,0

755,0

760,0

765,0

2013 2014 2015 2016 2017

Year

Pm

p

Incidence

Prevalence

Primary renal disease

Treatments modality

Blood transmitted diseases

Vascular access

Acute renal failure

Outcome

14

Epidemiology - Primary renal disease

15

The most common causes of renal failure in prevalence of patients in B&H in 2017

20

,1%

13

,8%

13

,0%

19

,7%

17

,2%

10

,1%

GN PN HT DM Misc. Unkn.

16

Prevalence of primary renal disease in the period 2013-2017 Years

GN;

150,7 pmp

PN;

103,9 pmp

DM;

147,8 pmp

HT

97,4 pmp

PKD;

40,8 pmp

20,0

40,0

60,0

80,0

100,0

120,0

140,0

160,0

2013 2014 2015 2016 2017

Year

Pm

p

17

Diabetic nephropathy in the incidence and prevalence of patients in the period 2006-2017 Years

Incidenc

Pmp=32,6

Prevalenc

Pmp=147,9

10,0

20,0

30,0

40,0

50,0

60,0

70,0

80,0

90,0

100,0

110,0

120,0

130,0

140,0

150,0

160,0

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

Year

Pm

p

Incidence (pmp) Prevalence (pmp)

Diabetic nephropathy in 2017 (age group of incident patients with DM)

18

N=

19;

16,5

%

N=

41;

35,7

%

N=

0;

0,0

% N=

11;

9,6

%

N=

44;

38,3

%

0,0

5,0

10,0

15,0

20,0

25,0

30,0

35,0

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

Age group

%

0

4

8

12

16

20

24

28

32

36

40

44

Patients

num

ber

Diabetic nephropathy in 2017 (age group of prevalent patients with DM)

19

N=

184; 3

5,2

%

N=

74; 1

4,2

%

N=

1; 0

,2%

N=

180; 3

4,5

%

N=

83; 1

5,9

%

0,0

5,0

10,0

15,0

20,0

25,0

30,0

35,0

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

Age group

%

0

20

40

60

80

100

120

140

160

180

Patients

num

ber

Diabetic nephropathy in year 2017 Diabetes typ

20

35

80

10

20

30

40

50

60

70

80

Bro

oj paci

jenata

Diabetic nephropathy

INCIDENT PATIENTS (at day 1)

DM - Typ I

DM - Typ II

271

251

100

125

150

175

200

225

250

275

Bro

oj paci

jenata

Diabetic nephropathy

PREVALENT PATIENTS

DM - Typ I

DM - Typ II

21

Balkan endemic nephropathy in year 2017 - Introduction

• Balkan endemic nephropathy is the most endemic renal disease in the north-east of Bosnia.

• Of 205 patients with Balkan nephropathy 89,7% were

older than 65 years of age.

• Patients with Balkan nephropathy constitute 7,7% of

the total number of dialysis patients in Bosnia and

Herzegovina.

22

Balkan endemic nephropathy in year 2017 - gaphical

7,7%

(205 patients)

Dialysis population

Balkan nephropathy

Balkan endemic nephropathy 2008 - 2017

23

31.12. godine Number of patients /pmp Males (%) Females (%)

2008* 305/86,9 pmp 49,8% 50,2%

2009 295/84,1 pmp 50,8% 49,2%

2010 301/85,8 pmp 50,5% 49,5%

2011 286/81,5 pmp 52,5% 47,5%

2012 271/77,2 pmp 50,9% 49,1%

2013 251/71,6pmp 50,6% 49,4%

2014 246/70,1 pmp 51,2% 48,8%

2015 234/66,3 pmp 51,3% 48,7%

2016 226/64,0 pmp 52,2% 47,8%

2017 205/58,1 pmp 50,2% 49,8%

* In 2008, the number of patients had its maximum. Since then, that number

has been falling steadily.

Incidence

Prevalence

Primary renal disease

Treatments modality

Blood transmitted diseases

Vascular access

Acute renal failure

Outcome

24

Epidemiology - Treatments modality

Treatments modality prevalent patients in last 5 years

89

,5%

3,3%

7,3%

89

,3%

3,2%

7,6%

88

,8%

2,8%

8,4%

85

,1%

3,1%

11,7%

83

,3%

3,3%

13,3%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

%

2013 2014 2015 2016 2017

Year

Transplantation

Peritoneal dialysis

Haemodyalisis

25

Incidence

Prevalence

Primary renal disease

Treatments modality

Blood transmitted diseases

Vascular access

Acute renal failure

Outcome

26

Blood transmitted diseases

27

Blood transmitted diseases – prevalent patients - year 2006-2017

31.12. HbsAg

(N / %)

HCV

(N / %)

HbsAg + HCV

(N / %)

HIV

(N)

MRSA+

(N)

2006 93 / 4,4% 342 / 16,3% 24 / 1,1% 1 1

2007 91 / 4,0% 352 15,5% 24 / 1,0% 1 0

2008 82 / 3,5% 309 13,2% 21 / 0,9% 1 5

2009 90 / 3,8% 308 12,9% 19 / 0,8% 1 5

2010 77 / 3,1% 336 13,5% 23 / 0,9% 1 8

2011 70 / 2,8% 296 11,9% 18 / 0,7% 1 9

2012 64 / 2,5% 273 10,8% 19 / 0,7% 1 6

2013 63 / 2,4% 246 9,3% 18 / 0,7% 1 9

2014 58 / 2,2% 228 / 8,5% 73 / 2,7% 1 6

2015 56 / 2,1% 242 / 9,1% 15 / 0,6% 1 4

2016 54 / 2,0% 173 / 6,5% 11 / 0,4% 1 3

2017 54 / 2,0% 158 / 6,0% 11 / 0,4% 1 3

16,3%

6,0%

5,0

7,0

9,0

11,0

13,0

15,0

17,0

2006 2017

Year

%

Anti HCV+

A significant reduction in % of the hepatitis “C”; From 16,3% in 2006 to 6,5% in 2017

1 patient

HbsAg+;

2,4 %

64 patients

HbsAg+HCV;

0,5 %

14 patients

HCV+;

6,0%

158 patients

Dialysis population

HbsAg +

Anti-HCV +

Anti-HCV+HbsAg

Anti-HIV +

28

Blood transmitted diseases - graphical (at day 31.12.2017)

Incidence

Prevalence

Primary renal disease

Treatments modality

Blood transmitted diseases

Vascular access

Acute renal failure

Outcome

29

Vascular access

Vascular access for haemodialysis – comparasion 2006-2017

30

Year 2006 2017

AV fistula (%) 81,7% 79,4%

Forearm (%) 95,1% 92,5%

Upper arm (%) 4,9% 7,5%

AV graft (%) 1,4% 0,2%

Forearm (%) 42,3% 40,0%

Upper arm (%) 11,5% 0,0%

Thigh (%) 46,2% 60,0%

Catheter temporary (%) 2,9% 8,5%

Subklavia vein (%) 50,0% 29,8%

Jugular vein (%) 48,1% 64,9%

Femoral vein (%) 1,9% 5,3%

Tunneled catheter (%) 3,6% 10,0%

AV Graft

5 pat.;

0,2%Katheter

temporary

188 pat.;

8,5%

Tuneled

katheter

221 pat.;

10,0%

AV Fistula

1756 pat.;

79,4%

31

Vascular access for haemodialysis - grafical (at day 31.12.2017)

Upper arm

1624 patients;

92,5%Forearm

132 patients;

7,5%

32

Vascular access for haemodialysis - AV fistula (at day 31.12.2017)

Thigh;

2 pacijentaForearm;

3 pacijenta

Upper arm;

0 pacijenata

33

Vascular access for haemodialysis - AV graft (at day 31.12.2017)

34

Vascular access for haemodialysis - Catheter temporary; (at day 31.12.2017)

Jugularis vein

122 patients;

64,9% Subklavia vein

56 patients;

29,8%

Femoralis vein

10 patients;

5,3%

Incidence

Prevalence

Primary renal disease

Treatments modality

Blood transmitted diseases

Vascular access

Acute renal failure

Outcome

35

Acute renal failure in 2017

Causes of acute renal failure in year 2017

222

150

77

50

100

150

200

250

Pa

tie

nts

n

um

be

r

Pre-renal Renal Post-renal

36

Outcome of acute renal failure in year 2017

50,1%

32,3%

17,6%

0,0

5,0

10,0

15,0

20,0

25,0

30,0

35,0

40,0

45,0

50,0

55,0

%

Deaths Cured Continuing chronic dialysis

program

37

Incidence

Prevalence

Primary renal disease

Treatments modality

Blood transmitted diseases

Vascular access

Acute renal failure

Outcome

38

Outcome

39

Mortality rate of patients on dialysis, (included patients at day 1), in period 2003-2017

12,4%

12,3%

12,9%

10,7%

10,1%

11,6%11,2%

10,5%

12,0%

13,3%

11,7%

13,7%

13,5%

10,2%

11,9%

9,0%

10,0%

11,0%

12,0%

13,0%

14,0%

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Year

%

40

The most common causes of death patients in 2017

Gastro-

intest.;

2,1%;

Infection;

7,2%

Unkn.;

10,7%

Cardiac;

45,2%

Vascul.;

19,3%

Cancer;

12,6%

Misc.;

2,1%

Living

unrelated;

13,3%

Cadaveric;

31,1%

Unknown;

1,7%

Living related;

54,0%

41

Patients with functional renal graft at day 31.12.2017 - graphical

42

Patients age group with functional renal graft at day 31.12.2017

2,5

% (

9 p

at.

) 47,2

% (

167 p

at.

)

44,9

% (

159 p

at.

)

4,8

% (

17 p

at.

)

0,6

% (

2 p

at.

)

0,0

5,0

10,0

15,0

20,0

25,0

30,0

35,0

40,0

45,0

50,0

%

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

Age group

43

Patients with functional renal graft at day 31.12.2017; By gender

248

106

0

25

50

75

100

125

150

175

200

225

250

Num

ber

of patients

wid

th funct

ional gra

ft

Male Female

Number of dialysis patients in Bosnia and Herzegovina continues to increase; 2002., when the Renal Registry was established, the number of patients was 1616 and 31.12.2017 2653 an increase of 64,2%.

The incidence of dialysis patients (at day 1) was 108,2 pmp in 2017.

The most common causes of renal failure in Bosnia and Herzegovina are:

Glomerulonephritis Pyelonephritis Diabetes mellitus (types I and II) Balkan endemic nephropathy Hypertension

44

Conclusions

Diabetes mellitus type I and II on 31.12.2017, is present in 522

patients, or 19,7% compared to the total number of prevalent

patients.

Balkan nephropathy on 31. 12. 2017, present in 205 patients, or

7,7% relative to the total number of prevalent patients and has a

decreasing trend.

45

Conclusions (continued)

In the last 5 years we can see a slight reduction or stagnation of

Blood transmitted diseases in dialysis patients, especially when it

comes to hepatitis.

Mortality of patients in 2017 was 12,4% of the total number of

patients in 2017 (3027) and is correlated with the age of patients,

because in 2017 there were a total of 46,7% of patients aged 65

and over year.

46

Conclusions (continued)