Editor's Choice – Vascular Access: 2018 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS)

Ankle brachial index Angiotensin converting enzyme Arteriovenous fistula (Synonym: Autogenous or native fistula) Arteriovenous graft (Synonym: Prosthetic graft) Brachiobasilic AVF Brachiocephalic AVF Basilic vein transposition Contrast enhanced magnetic resonance angiography Congestive heart failure Chronic kidney disease Cardiac output Carbon dioxide Cardiopulmonary recirculation Computed tomography angiography Cardiovascular disease Central venous catheter Central venous occlusive disease Digital brachial index Dialysis outcomes and practice patterns study Drug eluting balloon Distal revascularisation and interval ligation Digital subtraction angiography Duplex ultrasonography expanded polytetrafluoroethylene European Journal of Vascular and Endovascular Surgery European Society of Cardiology End stage renal disease European Society for Vascular Surgery Glomerular filtration rate Great saphenous vein Haemodialysis Catheter of any kind used for haemodialysis Haemodialysis Reliable Outflow device Human immunodeficiency virus Ischaemic monomelic neuropathy Inferior vena cava Kidney diseases outcome quality initiative Dialysis rate Lower extremity AVG Lower extremity atherosclerotic disease Low molecular weight heparin Mean arterial pressure Magnetic resonance angiography Magnetic resonance imaging Methicillin resistant Staphylococcus aureus Non-contrast enhanced magnetic resonance angiography Neointimal hyperplasia (Synonym: Myointimal hyperplasia) National Kidney Foundation for Kidney disease outcome quality initiative Negative pressure wound therapy Nephrogenic systemic fibrosis Non tunnelled central venous catheter (Synonym: indwelling catheter without cuff) Proximalisation of the arteriovenous anastomosis Peritoneal dialysis Peripherally inserted central venous catheter Pre-nephrology visit Percutaneous transluminal angioplasty (Synonym: balloon angioplasty) Access blood flow Blood pump flow delivered to the dialyser Radiocephalic AVF (Synonoym: Brescia-Cimino fistula) Randomised controlled trial Renal replacement therapy Revision using distal inflow Superficial femoral artery Femoral vein (formerly superficial femoral vein) Femoral vein transposition Former covered stent Tunnelled cuffed central venous catheter (Synonym: indwelling catheter with cuff) Ultrasound dilution technique Urea reduction ratio Vascular access Vascular access induced limb ischaemia Vascular Access Society Venous pressure Venous pressure adjusted for the mean arterial pressure Writing Committee The European Society for Vascular Surgery (ESVS), in line with its mission, appointed the Vascular Access (VA) Writing Committee (WC) to write the current clinical practice guidelines document for surgeons and physicians who are involved in the care of patients with haemodialysis (HD) and VA. The goal of these Guidelines is to summarise and evaluate all the currently available evidence to assist physicians in selecting the best management strategies for all patients needing VA or for pathologies derived from a VA. However, each physician must make the ultimate decision regarding the particular care of an individual patient.1Field M.J. Lohr K.N. Clinical practice guidelines: directions for a new program. Committee to advise the Public-Health Service on clinical practice guidelines. Institute of Medicine, 1990Google Scholar, 2Field M.J. Lohr K.N. Guidelines for clinical practice: from development to use. Institute of Medicine, 1992Google Scholar Patients with VA for HD are complex and also subject to significant clinical practice variability, although a valid evidence base is available to guide recommendations. The significant technical and medical advances in VA have enabled guidelines to be proposed with greater supporting evidence than before. Potential increases in healthcare costs and risks due to industry and public driven use of novel treatment options make the current guidelines increasingly important.3Dubois R.W. Dean B.B. Evolution of clinical practice guidelines: evidence supporting expanded use of medicines.Dis Manag. 2006; 9: 210-223Crossref PubMed Scopus (0) Google Scholar, 4Sood R. Sood A. Ghosh A.K. Non-evidence-based variables affecting physicians' test-ordering tendencies: a systematic review.Neth J Med. 2007; 65: 167-177PubMed Google Scholar, 5Manchanda P. Honka E. The effects and role of direct-to-physician marketing in the pharmaceutical industry: an integrative review.Yale J Health Policy Law Ethics. 2005; 5: 785-822PubMed Google Scholar, 6Win H.K. Caldera A.E. Maresh K. Lopez J. Rihal C.S. Parikh M.A. et al.Clinical outcomes and stent thrombosis following off-label use of drug-eluting stents.JAMA. 2007; 297: 2001-2009Crossref PubMed Scopus (292) Google Scholar Many clinical situations involving patients with HD and VA have not been studied by randomised clinical trials. Nevertheless, patient care must be delivered and clinical decisions made in these situations. Therefore, this document should also provide guidance when extensive level A evidence is unavailable and in these situations recommendations are determined on the basis of the best currently available evidence. By providing information on the relevance and validity of the quality of evidence, the reader will be able to gather the most important and evidence based information relevant to the individual patient. This document is intended to be a guide, rather than a set of rules, allowing flexibility for specific patients' circumstances. The current clinical practice guidelines document provides recommendations for the clinical care of patients with HD and VA including pre-operative, peri-operative and post-operative care and long-term maintenance. The VA WC was formed by members of the ESVS and Vascular Access Society (VAS) from different European countries, various academic and private hospitals, and includes vascular surgeons, nephrologists, radiologists and clinical nurses in order to maximise the applicability of the final guideline document. The WC met in September 2012 for the first time to discuss the purpose, contents, methodology and timeline of the following recommendations. The VA WC has performed a systematic literature search in the MEDLINE, EMBASE and COCHRANE Library databases for each of the different topics that are discussed and reviewed in this guidelines document. The latest literature search was performed by August 31st 2017. With regard to the evidence gathered, the following eligibility criteria have been applied:•Only peer reviewed published literature has been considered•Published abstracts or congress proceedings have been excluded•Randomised clinical trials (RCT) as well as meta-analyses and systematic reviews were searched with priority•Non-RCTs, non-controlled trials and well conducted observational studies (cohort and case control studies) were also included•Previous guidelines, position papers and published consensus documents have also been included as part of the review process when new evidence was absent•Minimising the use of reports of a single medical device or from pharmaceutical companies reduced the risk of bias across studies. A grading system based on the European Society of Cardiology (ESC) guidelines methodology was adopted.7ESC Recommendations for Guidelines Production [20.09.2016]. www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Guidelines-development/Writing-ESC-Guidelines].Google Scholar The level of evidence classification provides information about the study characteristics supporting the recommendation and expert consensus, according to the categories shown in Table 1.Table 1Levels of evidence.7ESC Recommendations for Guidelines Production [20.09.2016]. www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Guidelines-development/Writing-ESC-Guidelines].Google Scholar The recommendation grade indicates the strength of a recommendation. Definitions of the classes of recommendation are shown in Table 2.Table 2Grades of strength of recommendations according to the ESC grading system.7ESC Recommendations for Guidelines Production [20.09.2016]. www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Guidelines-development/Writing-ESC-Guidelines].Google Scholar For each recommendation, two members of the WC assessed the strength of a recommendation and the quality of supporting evidence independently. A full master copy of the manuscript with all recommendations was electronically circulated and approved by all WC members. Recommendations that required consensus were discussed and voted upon at meetings and by email among all members of the WC. This system permitted strong recommendations supported by low or very low quality evidence from downgraded RCTs or observational studies only when a general consensus among the WC members and reviewers was achieved. Meta-analyses are quoted in the recommendations according to the following rule: if the recommendation was either of high or low quality the meta-analysis was quoted and the individual studies were not explored. If it was a “grey area” and mixed opinions on the included meta-analysis studies were present, the original data were examined to clearly present the “mixed” findings within several studies. Two members of the WC have prepared each part of the guidelines document. An internal review process was performed before the manuscript was sent to the ESVS Guidelines Committee and selected invited independent external reviewers. External reviewers made critical suggestions, comments and corrections on all preliminary versions of these guidelines. In addition, each member participated in the consensus process concerning conflicting recommendations. The final document has been approved by the ESVS Guidelines Committee and submitted to the European Journal of Vascular and Endovascular Surgery (EJVES). Further updated guidelines documents on VA will be provided periodically by the ESVS when new evidence and/or new clinical practice arise in this field, which could occur every three years. To optimise the implementation of the current document, the length of the guidelines has been kept as short as possible to facilitate access to guideline information. Conflicts of interest from each WC member were collected prior to the writing process. These conflicts were assessed and accepted by each member of the WC and are reported in this document. In addition, the WC agreed that all intellectual work should be expressed without any interference beyond the honesty and professionalism of all its members during the writing process. Patients with acute renal failure or end stage renal disease require renal replacement therapy, which includes peritoneal dialysis (PD), haemodialysis (HD) or kidney transplantation (Fig. 1). A VA is essential for patients on HD and can be accomplished with central venous catheters (CVC), but also with arterialisation of a vein or by interposition of a graft between an artery and a vein for the insertion of HD needles. The blood flow available for HD should reach at least 300 ml/min and preferably 500 ml/min depending on the VA modality to allow a sufficient HD. Arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs) are established terms to characterise a special kind of VA in patients on HD. An AVF is defined as an autogenous anastomosis between an artery and a vein and an AVG is defined as a VA using a prosthetic graft. At the beginning of this millennium interventional radiologists and vascular surgeons attempted to clarify the terminology dealing with HD access.8Gray R.J. Sacks D. Martin L.G. Trerotola S.O. Reporting standards for percutaneous interventions in dialysis access. Technology Assessment Committee.J Vasc Intervent Radiol JVIR. 1999; 10: 1405-1415Abstract Full Text PDF PubMed Google Scholar, 9Sidawy A.N. Gray R. Besarab A. Henry M. Ascher E. Silva Jr., M. et al.Recommended standards for reports dealing with arteriovenous hemodialysis accesses.J Vasc Surg. 2002; 35: 603-610Abstract Full Text Full Text PDF PubMed Scopus (467) Google Scholar, 10NKF KDOQI Guidelines. 2006http://wwwkidneyorg/professionals/KDOQI/guideline_upHD_PD_VAGoogle Scholar Some of these definitions have been revised and11Lee T. Mokrzycki M. Moist L. Maya I. Vazquez M. Lok C.E. Standardized definitions for hemodialysis vascular access.Semin Dial. 2011; 24: 515-524Crossref PubMed Scopus (72) Google Scholar further refinements made; there is still ongoing discussion amongst VA specialists. Nevertheless outlined below are the definitions that are believed to be currently accepted by the majority of clinicians in the field. Incidence is the proportion of a given population developing a new condition or experiencing an event within a specified period of time. This could be for example, the number of patients experiencing an event (e.g. patients undergoing VA creation) divided by the number of a given population (e.g. the number of patients undergoing HD). For a disease, incidence can be expressed as the number of patients per million population per year. Prevalence is the total number of cases of a disease within a given population; it includes both new and continuing patients with a certain disease and is expressed as number of patients per million population. Prevalence is a function of incidence (new cases) and outcomes (death or cure). Point prevalence in %: Number of patients using a specific type of VA at a given point of time multiplied by 100 and divided by the number of patients with a VA at this time. Period prevalence in %: The mean number of patients using a specific VA over a given time (one year) multiplied by 100 and divided by all the patients using a VA during the same time period. Hospitalisation days/1000 access days: The numerator is the total number of days of hospitalisation for the study population. The denominator is calculated as the number of days from VA creation or the start date of a study period to permanent (unsalvageable) VA failure, the end of study period, death of the patient, transfer from the dialysis unit or a change in renal replacement modality (PD or transplantation). The calculated rate is the total number of hospitalisation days ⁄ total number of VA days multiplied by 1000 to express the number of hospitalisation days per 1000 VA days. Access abandonment: The day on which a VA is deemed to be permanently unusable or not suitable for cannulation. Primary VA: Creation of a functioning VA for the first time. Secondary VA: Ordinary VA creation with AVF or AVG at any location after a failed primary VA (tertiary VA excluded). Tertiary VA: VA using great saphenous vein (GSV) or femoral vein (FV) translocated to the arm or leg. Unusual VA procedures such as upper or lower limb arterio-arterial loops are included in this category. Transposition: Relocation of an autogenous vein to a new (more superficial) position in the soft tissues of the same anatomical area (e.g. an upper arm AVF with transposition of the basilic vein). Translocation: The prepared vein is completely disconnected and inserted in a new anatomical area to create an AVF. Superficialisation: The index vein is transposed in the subcutaneous tissue and positioned closer to the skin. Kaplan-Meier life table analysis: A statistical method for calculating time dependent clinical outcomes can be documented such as VA patencies, or infection free survival rates. Primary patency: The interval between VA creation and the first re-intervention (intervention free VA survival) for VA dysfunction or thrombosis, the time of measurement of patency or the time of its abandonment. Assisted primary patency: The interval between VA creation and the first occlusion (thrombosis free VA survival) or measurement of patency including operative/endovascular interventions to maintain the VA. Primary functional patency: The interval between the first use (first cannulation) of a newly created VA and the first re-intervention to rescue the VA or to its abandonment. Secondary patency: The interval between VA creation and the abandonment of this VA (i.e. thrombosis) after one or more interventions or the time of measurement of patency including achievement of a censored event (death, change of HD modality, loss of follow-up). Maturation and functionality of VA: Changes that occur in the VA after its creation (increase in VA flow and AVF diameter, wall structure changes, AVG tissue to graft incorporation) making it suitable over time for cannulation. Mature VA: A VA that is expected to be suitable for HD access and considered appropriate for cannulation with two needles and expected to deliver sufficient blood flow throughout the HD. Therefore it is a pre-cannulation definition. Functional VA: A VA is functional when it has been cannulated successfully with two needles, over a period of at least 6 HD sessions during a 30 day period, and delivered the prescribed blood flow throughout the HD and achieved adequate HD (usually at least 300 ml/ min). Therefore, it is a post-cannulation definition. Monitoring: Examination and evaluation of the VA by means of physical examination to detect physical signs that suggest the presence of VA dysfunction. Surveillance: Periodic evaluation of a VA using haemodynamic tests. This may trigger further diagnostic evaluation. VA induced (limb) ischaemia: Extremity malperfusion after VA creation. It can be classified in four stages:stage 1: slight coldness, numbness, pale skin, no painstage 2: loss of sensation, pain during HD or exercisestage 3: rest painstage 4: tissue loss affecting the distal parts of the limb, usually the digits This definition is more appropriate than ‘steal’ which describes the physiological phenomenon of (even retrograde) blood flow recruitment towards the AVF/AVG. Recirculation: The return of dialysed blood to the systemic circulation without full equilibration (NKF-DOQI definition). Kt/V: A parameter to quantify the adequacy of the HD: K=Dialyser clearance of urea, t=effective time of HD V=volume of urea distribution, approximately equal to the patient's body water (60% of the body mass). Early VA failure: A VA that has occluded within 24 hours of creation. Early dialysis suitability failure: A VA that cannot be used by the third month following creation despite radiological or surgical intervention. Late dialysis suitability failure: A VA that is not usable after more than 6 months despite radiological or surgical intervention. Cannulation failure: Failure is defined as the inability to place and secure two dialysis needles. Non-tunnelled CVC (ntCVC): An uncuffed catheter providing temporary VA for HD. Tunnelled cuffed CVC (tcCVC): A subcutaneously tunnelled dual lumen catheter with a cuff that can be used for VA if HD is expected to last for more than two weeks. Catheter related bacteraemia: Proven: Bacteraemia with at least one positive percutaneous peripheral vein blood culture and where either the same pathogen was cultured from the catheter tip or a blood culture drawn from a catheter that has a >3 fold greater bacterial colony count than those drawn from a peripheral vein. Probable: Bacteraemia with positive blood cultures obtained from a catheter and/or peripheral vein in a patient where there is no clinical evidence of an alternative source of an infection. Catheter exit site infection: Proven: The presence of a purulent discharge or erythema, induration/and or tenderness at the catheter exit site with a positive bacteriological culture of the serous discharge. Probable: The clinical signs of infection with negative cultures from the discharge or blood without signs of irritation from gauze, stitches or the cleansing agent. Catheter tunnel infection: Proven: The presence of purulent discharge from the tunnel or erythema, induration and/or tenderness over the catheter tunnel with a positive culture. Probable: Clinical signs of infection around the catheter site with negative cultures from the discharge or blood. Primary catheter site patency: Interval between catheter insertion and the first intervention to restore the catheter's function. Secondary catheter site patency: Interval between catheter insertion and exchange or removal of the catheter for any reason. Continuous catheter site: The time period from initial catheter insertion to catheter site abandonment for any reason including the time period after continuous catheter exchanges in the same target vessel. The time period and number of exchanges are documented e.g. 12 months [3 catheters]. Catheter dysfunction: This is the first occurrence of either a peak flow of 200 ml/minute or less for 30 minutes during HD, a mean blood flow of 250 ml/minute or less during two consecutive dialyses or the inability to initiate HD resulting from an inadequate blood flow, despite attempts to restore patency. Chronic kidney disease (CKD) is a worldwide public health problem. CKD is classified into five stages (Table 3), but renal insufficiency is restricted to stages 3–5, with a glomerular filtration rate (GFR) below 60 ml/min per 1.73 m2 for 3 months or more irrespective of the cause.12K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification.Am J Kidney Dis. 2002; 39: S1-266PubMed Google ScholarTable 3Classification of chronic kidney disease based on glomerular filtration rate (GFR).8Gray R.J. Sacks D. Martin L.G. Trerotola S.O. Reporting standards for percutaneous interventions in dialysis access. Technology Assessment Committee.J Vasc Intervent Radiol JVIR. 1999; 10: 1405-1415Abstract Full Text PDF PubMed Google Scholar, 9Sidawy A.N. Gray R. Besarab A. Henry M. Ascher E. Silva Jr., M. et al.Recommended standards for reports dealing with arteriovenous hemodialysis accesses.J Vasc Surg. 2002; 35: 603-610Abstract Full Text Full Text PDF PubMed Scopus (467) Google Scholar, 10NKF KDOQI Guidelines. 2006http://wwwkidneyorg/professionals/KDOQI/guideline_upHD_PD_VAGoogle Scholar, 11Lee T. Mokrzycki M. Moist L. Maya I. Vazquez M. Lok C.E. Standardized definitions for hemodialysis vascular access.Semin Dial. 2011; 24: 515-524Crossref PubMed Scopus (72) Google ScholarStageDescriptionGFR mL/min/1.73 m2Stage 1Kidney damage with normal or elevated GFR90+Stage 2Kidney damage with mildly decreased GFR60–89Stage 3Moderately decreased GFR30–59Stage 4Severely decreased GFR15–29Stage 5End stage renal disease (ESRD)<15 or on dialysis Open table in a new tab The true incidence and prevalence of CKD within a community are difficult to ascertain as early to moderate CKD is usually asymptomatic. Most studies point to a prevalence of CKD of around 10%, albuminuria of around 7%, and GFR below 60 ml/min per 1.73 m2 of around 3%.13Coresh J. Astor B.C. Greene T. Eknoyan G. Levey A.S. Prevalence of chronic kidney disease and decreased kidney function in the adult US population: Third National Health and Nutrition Examination Survey.Am J Kidney Dis. 2003; 41: 1-12Abstract Full Text Full Text PDF PubMed Google Scholar, 14Levey A.S. de Jong P.E. Coresh J. El Nahas M. Astor B.C. Matsushita K. et al.The definition, classification, and prognosis of chronic kidney disease: a KDIGO Controversies Conference report.Kidney Int. 2011; 80: 17-28Abstract Full Text Full Text PDF PubMed Scopus (839) Google Scholar, 15Wetzels J.F. Kiemeney L.A. Swinkels D.W. Willems H.L. den Heijer M. Age- and gender-specific reference values of estimated GFR in Caucasians: the Nijmegen Biomedical Study.Kidney Int. 2007; 72: 632-637Abstract Full Text Full Text PDF PubMed Scopus (205) Google Scholar CKD stage 5 (ESRD) is characterised by GFR below 15 ml/min per 1.73 m2 and includes two phases: the first one is treated conservatively without dialysis; when the second phase follows, the initiation of renal replacement therapy (RRT) in the form of dialysis or transplantation is required to sustain life. The incidence of CKD stage 5 refers to the number of patients with ESRD beginning RRT, thus failing to take into account patients not treated by RRT and underestimating the overall true incidence of ESRD. In the dialysis population, prevalence is a function of the incidence (new cases) and outcome (transplantation or death) rates of ESRD. The number of patients per year starting RRT has shown an exponential rise.16Port F.K. End-stage renal disease: magnitude of the problem, prognosis of future trends and possible solutions.Kidney Int Suppl. 1995; 50: S3-6PubMed Google Scholar Such a large number of CKD patients requiring dialysis may have three main causes: patient selection, competitive risks and a true increase in CKD incidence: 1. Selection of patients for RRT: the steep increase in the incidence of older patients suggests that those very old and/or those affected by particularly severe comorbidities were not given access to dialysis in the first decades of RRT, compared with the more recent years. 2. Competitive risks: a study suggested that the number of deaths where CKD is the underlying cause of death increased by 82% between 1990 (27th in the global death rank) and 2010 (18th in the global death rank).17Lozano R. Naghavi M. Foreman K. Lim S. Shibuya K. Aboyans V. et al.Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010.Lancet. 2012; 380: 2095-2128Abstract Full Text Full Text PDF PubMed Scopus (5396) Google Scholar A high risk of death exists even in patients in the early stages of CKD, with many individuals in stages 3 and 4 dying before starting RRT.18Keith D.S. Nichols G.A. Gullion C.M. Brown J.B. Smith D.H. Longitudinal follow-up and outcomes among a population with chronic kidney disease in a large managed care organization.Arch Intern Med. 2004; 164: 659-663Crossref PubMed Scopus (1075) Google Scholar, 19Go A.S. Chertow G.M. Fan D. McCulloch C.E. Hsu C.Y. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization.N Engl J Med. 2004; 351: 1296-1305Crossref PubMed Scopus (6433) Google Scholar In fact, a reduced GFR is considered one of the most important risk factors for coronary heart disease.20Sarnak M.J. Levey A.S. Schoolwerth A.C. Coresh J. Culleton B. Hamm L.L. et al.Kidney disease as a risk factor for development of cardiovascular disease: a statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention.Hypertension. 2003; 42: 1050-1065Crossref PubMed Scopus (680) Google Scholar Substantial improvements in the treatment of cardiac diseases and in survival have occurred in recent decades and this has allowed many patients to survive in the more advanced CKD stages and to require RRT. 3. The true increase in CKD incidence: it may also be possible that the increased incidence of ESRD reflects increases in the underlying prevalence of CKD. The Framingham Heart Study has shown that the incidence of type 2 diabetes has doubled from the 1970s to the 1990s.21Fox C.S. Pencina M.J. Meigs J.B. Vasan R.S. Levitzky Y.S. D'Agostino Sr., R.B. Trends in the incidence of type 2 diabetes mellitus from the 1970s to the 1990s: the Framingham Heart Study.Circulation. 2006; 113: 2914-2918Crossref PubMed Scopus (244) Google Scholar Furthermore, potentially nephrotoxic drugs, such as non-steroidal anti-inflammatory drugs, antibiotics and chemotherapy agents are used more commonly. Finally, reduced mortality from cardiovascular diseases and cancer may be associated with an increase in the number of patients reaching ESRD. Data related to the prevalence of CKD stage 5 are lacking, except for those of registries of ESRD patients treated by dialysis or transplantation. In the USA, of the 547,982 prevalent ESRD patients in 2008, 70 percent were being treated by dialysis while 30 percent had a functioning kidney transplant. In 2008 alone, 112,476 patients entered the US ESRD program. Adjusted rates for incident and prevalent ESRD are 351 and 1,699 cases per million population, respectively. Diabetes and hypertension account for 44% and 27.9% of all causes of incident ESRD, respectively.22United States Renal Data System USRDS 2010 annual data report: Atlas of chronic kidney disease and end-stage renal disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Disease, Bethesda, MD2010Google Scholar The prevalence of a disease increases if the patient survival increases with a constant incidence rate or if the incidence rate increases with a constant survival rate. Thus the rising prevalence of treated ESRD can be attributed either to the increase in the number of patients who start RRT each year and/or to the increased survival of patients with ESRD. Since the incidence rates of treated ESRD have flattened in recent years, longer lifespans of prevalent ESRD patients may partially explain the steady growth of this population.22United States Renal Data System USRDS 2010 annual data report: Atlas of chronic kidney disease and end-stage renal disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Disease, Bethesda, MD2010Google Scholar Continuing global efforts should be made in the prevention and treatment of acute and especially chronic conditions potentially leading to ESRD, in particular diabetes and hypertension. The global epidemiology of ESRD is heterogeneous and influenced by several factors. Consequently, the incidence and prevalence of ESRD are markedly different from country to country (Table 4). Disparities in the incidence and prevalence of ESRD within and between developed countries reflect racial and ethnic diversities as well as their impact on the prevalence of diabetes and hypertension in respective countries and communities. The incidence is higher among