the 2-year survival of patients starting rrt has progressively increased for cohorts from 2001 to 2006 , measured either as overall survival for patients starting rrt ( to 82.2% for the cohort starting in 2006 reported in the era - edta registry 2012 report ) , on dialysis ( 79.7% ) or receiving living - related kidney transplantation ( 98.3% ) ( figure  1 ) [ 13 ] . in contrast , 2-year survival for cadaveric kidney transplantation remains stable at 96.096.1% for cohorts starting from 2003 to 2006 pointing to a plateau that would need novel approaches to be surpassed . these data are in agreement with other registries reporting increasing overall survival of patients starting rrt in the last decade [ 47 ] . similar improvements were observed for 5-year survival , pointing to an overall improvement in the standard of care , unlike the us situation in the 1990s , in which progressive increases in survival at 12 and 24 months were associated with decreasing survival at 5 years [ 4 , 8 ] . drop in longer - term survival and whether a similar phenomenon occurred outside this country still need detailed studies , in search of lessons that might be learned and applied to improve the current standard of care . on the dark side , data point to persistent inequalities between european citizens in incidence and prevalence of rrt and in access to transplantation . living in greece , belgium ( both french- and dutch - speaking ) or portugal ( the gbp countries ) is associated with higher chances of initiating rrt than living in other european countries . very high incidence of rrt was also reported in israel and georgia in 2012 and in turkey in 2011 and 2010 . the adjusted rrt incidence for gbp countries was 188 , 201 - 174 and 220 pmp in 2012 , respectively ( although portugal data are unadjusted ) . this compares with 122 , 114 and 97 pmp in the netherlands or spanish regions ( galicia , castilla - leon ) bordering portugal ( figure  2a ) . moreover , these differences persist when prevalence is examined ( figure  2c ) , although prevalence / incidence values are lower for high incidence countries ( figure  3 ) . one potential explanation is more stringent patient selection in low incidence countries , although better on - rrt care may also contribute . in lower income countries , the low incidence of rrt may represent lack of access to needed healthcare ( e.g. montenegro 26 pmp ) . however , how can the high incidence and prevalence of rrt in the gbp countries be explained ? do gbp citizens have access to rrt techniques that are denied to citizens in other high income countries , e.g. adjusted incidence of rrt 100 pmp in scotland and 77 pmp in finland ? are there local genetic or environmental factors that favour progression of ckd and have not been tackled by public health authorities ? are there perverse incentives or forces that favour ckd progression or initiation of rrt ? or it is just a matter of reporting methods or of nephrologist beliefs regarding the timing of initiation of rrt when hard evidence is lacking ? unravelling the underlying reasons for the observed inequalities is an urgent research need : only when the causes are known can corrective measures be applied . table  1.potential causes of differences in rrt incidence and prevalencevery concerning  overuse of rrt  denial of access to rrt  financial incentives to initiate rrtconcerning  different incidence or progression of ckd  public health system fails to prevent development of ckd  healthcare system structure or access results in suboptimal ckd care  different views on the relative value of rrt versus conservative management of esrdother  different data reporting methods  refusal of rrt by an informed population when rrt is offered potential causes of differences in rrt incidence and prevalence several countries with low incidence and prevalence of rrt have higher incomes than countries with higher prevalence ( figure  4a ) . the differences do not appear to depend on a better public health system or success in preventing ckd progression in those countries with high income . thus , some countries with higher income and low rrt incidence start rrt at a median younger age than countries which have both lower income and higher incidence of rrt . in this regard , low overall incidence and prevalence of rrt is frequently associated with low incidence and prevalence of rrt in those aged > 75 years ( figures  2b , d and 4c ) . thus , the age pattern is consistent with denial of rrt to the elderly , refusal of rrt by the elderly or different criteria for indicating conservative treatment versus rrt in younger or elderly patients in countries with low rrt incidence . in these high income countries , low rrt incidence in the elderly does not appear to depend on economic constraints , as is the case in low income countries . the low rrt incidence may be based on the genuine belief that conservative treatment is the best option for elderly patients with esrd [ 9 , 10 ] . in this regard , there is an urgent need for hard evidence on the relative merits of conservative treatment versus rrt in the elderly as well as on the optimal timing of rrt start . if indeed conservative management has clear advantages , then in some countries overdialysis might be an issue . in this regard , a recent survey of nephrologists from 11 european countries disclosed very different practices regarding start of rrt in uncomplicated relatively young ( 60-year - old ) patients : the estimated glomerular filtration rates ( egfrs ) at which rrt would be started by different nephrologists ranged from 5 to 20 ml / min/1.73 m and this was the most important parameter to initiate rrt in such a patient for a majority of nephrologists . obviously , starting at an egfr of 5 or 20 ml / min/1.73 m may have a great impact on the incidence of rrt . if the same range would be applied to those over 75 years of age ( which was not the subject of the study ) , it would mean the difference between initiating and never initiating rrt for a great number of patients . interestingly , nephrologists from countries with a high incidence of rrt more often believed that starting at a gfr > 10.5 ml / min/1.73 m is always beneficial compared with respondents from low incidence countries ( 18 versus 6% ) . furthermore , the target egfr was higher for nephrologists working at for - profit centres . further information is needed about the gfr at initiation of rrt in different countries as well as on the use of and acceptance by patients and doctors and outcomes of conservative management of esrd in the elderly . the fact that differences in prevalence are lower than differences in incidence is concordant with prevalence / incidence value data ( figure  3 ) and can be interpreted as a high rate of patient loss in some high incidence countries . whether these shorter periods on rrt in some countries with a high incidence of rrt result in improved patient quality of life and are indeed appreciated by the patient there are additional hypotheses potentially explaining the lower incidence of rrt coupled to a younger mean age at start of rrt in some high income countries . patients may be dying earlier from cardiovascular disease and , thus , not living long enough to need rrt . however , life expectancy does not differ much between countries selected for this commentary , except for low income montenegro ( figure  4b ) . public health may also impact the incidence and prevalence of ckd and , thus , of esrd . factors potentially involved include the presence of toxins in the environment or food ( i.e. the exposome , as an example , aristolochic nephropathy ) , over - the - counter medication policies ( allowing unrestricted access to nephrotoxic drugs ) or country - level policies regarding salt or phosphate content in the diet . in addition , the healthcare system may also impact , as an example , whether there is universal unrestricted access to healthcare or to nephrologists . the percentage of patients on rrt who have a functioning kidney graft ranges from 7% in bosnia and herzegovina to 60% in norway , finland and iceland . also worrisome is the fact that rrt epidemiology data from some countries big and small ( e.g. germany , ireland , hungary and italy , among others ) at the core of europe are not available , as it was the case for 2011 and , except for some parts of italy , for 2010 [ 13 ] . this virtual black - out makes comparison with other european countries difficult that could improve the standard of care and to detect pockets of substandard care or endemic ckd hotspots . in summary , the era - edta registry continues to provide a wealth of data on the epidemiology of rrt . key points of this year 's report include ( i ) the improving outcomes for patients on rrt , with exception of recipients of cadaveric donor kidneys , ( ii ) the persistence of inequalities in rrt incidence and prevalence and transplantation availability in different european countries that may hide ckd hotspots , substandard ckd care , overuse of rrt or lack of access to needed rrt ; and ( iii ) a preoccupying lack of data from key countries . there is an urgent need to study the factors underlying the inequalities in rrt incidence and prevalence and to identify and correct potential substandard care for some european citizens . renal replacement therapy in europe : a summary of the 2012 era  edta registry annual report .