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Lancet. 2017 May 27;389(10084):2128-2137. doi: 10.1016/S0140-6736(17)30063-6. Epub 2017 Mar 20.

Mortality risk disparities in children receiving chronic renal replacement therapy for the treatment of end-stage renal disease across Europe: an ESPN-ERA/EDTA registry analysis.

Author information

ESPN/ERA-EDTA Registry, Amsterdam, Netherlands.
Division of Paediatric Nephrology, University of Heidelberg, Center for Paediatrics and Adolescent Medicine, Heidelberg, Germany.
Department of Medical Informatics and Clinical Research Unit, Academic Medical Center, Amsterdam, Netherlands.
Department of Paediatrics, Belarusian State Medical University, Minsk, Belarus.
Paediatric Nephrology Department, Baskent University, Ankara, Turkey.
Oslo University Hospital Rikshospitalet, Department of Paediatrics, Oslo, Norway.
Service de néphrologie pédiatrique, CHU de Tours-Hôpital Clocheville, Tours, France.
Department of Paediatric Nephrology, Radboud University Medical Center, Nijmegen, Netherlands.
Paediatric Nephrology, University Hospital La Paz, Madrid, Spain.
Department of Medicine, Zealand University Hospital, Roskilde, Denmark.
Unidade de Nefrologia e Transplantação Renal, Departamento de Pediatria, Hospital de Sta Maria, Centro Académico de Medicina de Lisboa, Lisbon, Portugal.
Department of Paediatrics Nephrology Unit, University Hospital Centre 'Mother Tereza', Tirana, Albania.
Department Paediatrics, Nephrology and Hypertension, Medical University of Gdansk, Gdansk, Poland.
Department of Paediatrics, Bordeaux University Hospital, Bordeaux, France.
ESPN/ERA-EDTA Registry, Amsterdam, Netherlands; ERA-EDTA Registry, Amsterdam, Netherlands. Electronic address:
Department of Paediatric Nephrology, Emma Children's Hospital Academic Medical Center, Amsterdam, Netherlands.



We explored the variation in country mortality rates in the paediatric population receiving renal replacement therapy across Europe, and estimated how much of this variation could be explained by patient-level and country-level factors.


In this registry analysis, we extracted patient data from the European Society for Paediatric Nephrology/European Renal Association-European Dialysis and Transplant Association (ESPN/ERA-EDTA) Registry for 32 European countries. We included incident patients younger than 19 years receiving renal replacement therapy. Adjusted hazard ratios (aHR) and the explained variation were modelled for patient-level and country-level factors with multilevel Cox regression. The primary outcome studied was all-cause mortality while on renal replacement therapy.


Between Jan 1, 2000, and Dec 31, 2013, the overall 5 year renal replacement therapy mortality rate was 15·8 deaths per 1000 patient-years (IQR 6·4-16·4). France had a mortality rate (9·2) of more than 3 SDs better, and Russia (35·2), Poland (39·9), Romania (47·4), and Bulgaria (68·6) had mortality rates more than 3 SDs worse than the European average. Public health expenditure was inversely associated with mortality risk (per SD increase, aHR 0·69, 95% CI 0·52-0·91) and explained 67% of the variation in renal replacement therapy mortality rates between countries. Child mortality rates showed a significant association with renal replacement therapy mortality, albeit mediated by macroeconomics (eg, neonatal mortality reduced from 1·31 [95% CI 1·13-1·53], p=0·0005, to 1·21 [0·97-1·51], p=0·10). After accounting for country distributions of patient age, the variation in renal replacement therapy mortality rates between countries increased by 21%.


Substantial international variation exists in paediatric renal replacement therapy mortality rates across Europe, most of which was explained by disparities in public health expenditure, which seems to limit the availability and quality of paediatric renal care. Differences between countries in their ability to accept and treat the youngest patients, who are the most complex and costly to treat, form an important source of disparity within this population. Our findings can be used by policy makers and health-care providers to explore potential strategies to help reduce these health disparities.



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