Laboratory-based surveillance of chronic kidney disease in people with private health coverage in Brazil.

BACKGROUND: Although approximately 25% of Brazilians have private health coverage (PHC), studies on the surveillance of chronic kidney disease (CKD) in this population are scarce. The objective of this study was to estimate the prevalence of CKD in individuals under two PHC regimes in Brazil, who total 8,335,724 beneficiaries. METHODS: Outpatient serum creatinine and proteinuria results of individuals from all five regions of Brazil, ≥ 18 years of age, and performed between 10/01/2021 and 10/31/2022, were analyzed through the own laboratory network database. People with serum creatinine measurements were evaluated for the prevalence and staging of CKD, and those with simultaneous measurements of serum creatinine and proteinuria were evaluated for the risk category of the disease. CKD was classified according to current guidelines and was defined as a glomerular filtration rate (GFR) < 60 ml/min/1.73 m² estimated by the 2021 CKD-EPI equation. RESULTS: The number of adults with serum creatinine results was 1,508,766 (age 44.0 [IQR, 33.9-56.8] years, 62.3% female). The estimated prevalence of CKD was 3.8% (2.6%, 0.8%, 0.2% and 0.2% in CKD stages 3a, 3b, 4 and 5, respectively), and it was higher in males than females (4.0% vs. 3.7%, p < 0.001, respectively) and in older age groups (0.2% among 18-29-year-olds, 0.5% among 30-44-year-olds, 2.0% among 45-59-year-olds, 9.4% among 60-74-year-olds, and 32.4% among ≥ 75-year-olds, p < 0.001) Adults with simultaneous results of creatinine and proteinuria were 64,178 (age 57.0 [IQR, 44.8-67.3] years, 58.1% female). After adjusting for age and gender, 70.1% were in the low-risk category of CKD, 20.0% were in the moderate-risk category, 5.8% were in the high-risk category, and 4.1% were in the very high-risk category. CONCLUSION: The estimated prevalence of CKD was 3.8%, and approximately 10% of the participants were in the categories of high or very high-risk of the disease. While almost 20% of beneficiaries with PHC had serum creatinine data, fewer than 1% underwent tests for proteinuria. This study was one of the largest ever conducted in Brazil and the first one to use the 2021 CKD-EPI equation to estimate the prevalence of CKD.

Supply/demand ratio for medical consultations, diagnostic tests and chronic kidney disease monitoring in the Brazilian National Health System: a descriptive study, state of São Paulo, Brazil, 2019. / Razão oferta/necessidade de consultas médicas, exames de diagnóstico e acompanhamento da doença renal crônica no Sistema Único de Saúde: estudo descritivo, estado de São Paulo, 2019.

OBJECTIVE: To determine the supply/demand ratio for procedures related to diagnosis and treatment for chronic kidney disease in the Brazilian National Health System (SUS), in the state of São Paulo, Brazil, 2019. METHODS: This was a descriptive study, using data from the SUS outpatient and hospital information systems. The numbers of medical consultations, diagnostic and chronic kidney disease monitoring tests, performed in the period, were compared with the demand estimation, obtained through ministerial guidelines. RESULTS: Exclusive SUS users were 28,791,244, and individuals with arterial hypertension and/or diabetes mellitus, 5,176,188. The number of procedures performed and the ratio between this number and the needs of the population were 389,414 consultations with nephrologists (85%); 11,540,371 serum creatinine tests (223%); 705,709 proteinuria tests (14%); 438,123 kidney ultrasounds (190%); and 1,045 kidney biopsies (36%). CONCLUSION: In the chronic kidney disease care in the SUS it could be seen simultaneous existence of lack of supply, waste and inadequate screening of important procedures.

Razão oferta/necessidade de consultas médicas, exames de diagnóstico e acompanhamento da doença renal crônica no Sistema Único de Saúde: estudo descritivo, estado de São Paulo, 2019 / Relación oferta/necesidad de consultas médicas, pruebas diagnósticas y seguimiento de la enfermedad renal crónica en el Sistema Único de Salud: estudio descriptivo, São Paulo, Brasil, 2019 / Supply/demand ratio for medical consultations, diagnostic tests and chronic kidney disease monitoring in the Brazilian National Health System: a descriptive study, state of São Paulo, Brazil, 2019

Objetivo: Determinar a razão oferta/necessidade de procedimentos relacionados com o diagnóstico e assistência à doença renal crônica no Sistema Único de Saúde (SUS), no estado de São Paulo, Brasil, 2019. Métodos: Estudo descritivo, utilizando dados dos sistemas de informações ambulatoriais e hospitalares do SUS. Os números de consultas médicas e exames diagnósticos e de acompanhamento da doença renal realizados no período foram comparados com as estimativas de necessidade obtidas por diretrizes ministeriais. Resultados: Usuários exclusivos do SUS eram 28.791.244, e indivíduos com hipertensão e/ou diabetes mellitus, 5.176.188. O número de procedimentos realizados e a razão entre esse número e a necessidade da população foram de 389.414 consultas com nefrologista (85%); 11.540.371 dosagens de creatinina sérica (223%); 705.709 dosagens de proteinúria (14%); 438.123 ultrassonografias renais (190%); e 1.045 biópsias renais (36%). Conclusão: Na assistência à doença renal crônica no SUS existem, simultaneamente, falta de oferta, desperdício e rastreamento deficiente de procedimentos importantes.

Objetivo: Determinar la relación oferta/necesidad de procedimientos relacionados con el diagnóstico y atención de la enfermedad renal crónica en Sistema Único de Salud (SUS) del Estado de São Paulo, Brasil, en 2019. Métodos: Estudio descriptivo utilizando datos de los sistemas de información ambulatoria y hospitalaria del SUS. Se comparó el número de consultas médicas, pruebas de diagnóstico y seguimiento de la enfermedad renal realizados con las estimaciones de necesidad recomendadas por directrices ministeriales. Resultados: Los usuarios exclusivos de SUS fueron 28.791.244 e hipertensos y/o diabéticos, 5.176.188. El número de procedimientos realizados y la relación entre este número y la necesidad de la población fueran de 389.414 consultas con nefrólogo (85%); 11.540.371 determinaciones de creatinina sérica (223%); 705.709 determinaciones de proteinuria (14%); 438.123 ecografías renales (190%); y 1.045 biopsias renales (36%). Conclusión: En la atención de enfermedad renal en SUS existe, simultáneamente, falta de oferta, desperdicio y seguimiento deficiente de procedimientos importantes.

Objective: To determine the supply/demand ratio for procedures related to diagnosis and treatment for chronic kidney disease in the Brazilian National Health System (SUS), in the state of São Paulo, Brazil, 2019. Methods: This was a descriptive study, using data from the SUS outpatient and hospital information systems. The numbers of medical consultations, diagnostic and chronic kidney disease monitoring tests, performed in the period, were compared with the demand estimation, obtained through ministerial guidelines. Results: Exclusive SUS users were 28,791,244, and individuals with arterial hypertension and/or diabetes mellitus, 5,176,188. The number of procedures performed and the ratio between this number and the needs of the population were 389,414 consultations with nephrologists (85%); 11,540,371 serum creatinine tests (223%); 705,709 proteinuria tests (14%); 438,123 kidney ultrasounds (190%); and 1,045 kidney biopsies (36%). Conclusion: In the chronic kidney disease care in the SUS it could be seen simultaneous existence of lack of supply, waste and inadequate screening of important procedures.

Quality indicators for primary health care in chronic kidney disease in the public service of a city in the State of São Paulo, Brazil / Qualidade de atenção primária em doença renal crônica em um serviço público de um município do Estado de São Paulo, Brasil / Calidad de los cuidados de salud en la atención primaria relacionados con la enfermedad crónica de riñón en un servicio público en una ciudad del Estado de São Paulo, Brasil

Abstract: Complications of chronic kidney disease (CKD) can be avoided when promptly diagnosed and treated. The objective was to describe quality indicators of CKD detection and health care in the primary care public service of a city in the State of São Paulo, Brazil. This retrospective study analyzed charts of patients who attended primary care in the public service between November 2019 and February 2020. We selected 10 health quality indicators based on their scientific relevance and availability from the medical records that could express how CKD was identified and managed in primary health care. We estimated the adequate percentage of health indicators with data from 1,066 individuals who had ≥ one risk factor for CKD: hypertension, diabetes, or > 60 years old. Among patients, 79.4% had information on serum creatinine, whereas 58.8% were investigated for proteinuria. Blood pressure data were found in 98.9% of the records. The percentage of patients with blood pressure < 140x90mmHg, glycosylated hemoglobin < 6.5% and LDL-cholesterol < 100mg/dL was 79.2%, 49.2%, and 33.3%, respectively. Renin-angiotensin system blockers were prescribed to 82.8% of the patients with hypertension and CKD. Serum potassium was measured in 35.7% for those who were using renin-angiotensin system blockers. Among those people with CKD, 16.7% had CKD assigned in the medical records as a diagnose. Among those participants at higher risk for CKD, the referral rate to a nephrologist was 31.6%. This study confirmed some missed quality indicators of CKD in primary healthcare. Our results may help administrators develop public policies that improve health care for individuals at high risk for CKD. Long-term follow-up of the health indicators we proposed here will be useful to assess the impact of policy intervention.

Resumo: As complicações da doença renal crônica (DRC) podem ser evitadas quando a doença é diagnosticada e tratada oportunamente. O estudo teve como objetivo descrever a qualidade dos indicadores da detecção e assistência para a DRC no sistema púbico de saúde em um município do Estado de São Paulo, Brasil. O estudo retrospectivo analisou prontuários de pacientes que utilizaram serviços de atenção primária no sistema público entre novembro de 2019 e fevereiro de 2020. Selecionamos dez indicadores de qualidade com base na relevância científica e disponibilidade, a partir dos prontuários médicos. Calculamos o percentual de adequação com dados de 1.066 indivíduos que apresentavam ≥ 1 fatores de risco para DRC: hipertensão, diabetes ou idade > 60 anos. No total, 79,4% dos pacientes apresentavam informação sobre creatinina sérica, e 58,8% foram investigados para proteinúria. Dados de pressão arterial foram encontrados em 98,9% dos prontuários. As proporções de pacientes com pressão arterial < 140x90mmHg, hemoglobina glicada < 6,5% e LDL < 100mg/dL foram 79,2%, 49,2% e 33,3%, respectivamente. Os antagonistas do sistema renina-angiotensina foram prescritos em 82,8% dos pacientes com hipertensão e DRC. O potássio sérico foi medido em 35,7% dos pacientes em uso de antagonistas do sistema renina-angiotensina. Entre os indivíduos com DRC, 16,7% tinham esse diagnóstico registrado no prontuário médico. Entre os participantes com risco mais elevado de DRC, 31,6% foram encaminhados para um nefrologista. O estudo confirmou a falta de alguns indicadores de qualidade para DRC na assistência primária. Os resultados podem ajudar gestores a desenvolverem políticas públicas que melhorem a assistência para indivíduos com risco maior de DRC. O seguimento a longo prazo dos indicadores de saúde propostos aqui será útil para avaliar o impacto dessa política de intervenção.

Resumen: Las complicaciones de la enfermedad crónica de riñón (ECR) se pueden evitar cuando esta enfermedad se diagnostica con prontitud y se trata. El objetivo fue describir indicadores de calidad en la detección de ECR, así como la asistencia en el servicio público de una ciudad, en el Estado de São Paulo, Brasil. Este estudio retrospectivo analizó fichas de pacientes que acudían a atención primaria en el servicio público, entre noviembre 2019 y febrero 2020. Seleccionamos 10 indicadores de calidad en salud, basados en relevancia científica y disponibilidad de registros médicos. Calculamos el porcentaje de adecuación de ellos con datos de 1.066 personas que tenían ≥ 1 factor de riesgo ECR: hipertensión, diabetes, o > 60 años. Un 79,4% de los pacientes tenían información sobre la creatinina sérica, y se investigó a un 58,8% en el caso de la proteinuria. Los datos de presión sanguínea se encontraron en un 98,9% de los registros. El porcentaje de pacientes con presión sanguínea < 140x90mmHg, hemoglobina glicada < 6,5% y LDL < 100mg/dL fue 79,2%, 49,2%, y 33,3%, respectivamente. Se prescribieron bloqueadores del sistema renina-angiotensina a un 82,8% de los pacientes con hipertensión y ECR. Se midió el potasio sérico en un 35,7% de aquellos quienes estaban usando bloqueadores del sistema renina-angiotensina. Entre aquellas personas con ECR, 16,7% había ECR asignado en los registros médicos como diagnosis. Entre aquellos participantes en riesgo mayor por ECR, la tasa de derivación a un nefrólogo fue 31,6%. Este estudio confirmó algunos indicadores de calidad olvidados de ECR en los cuidados de salud en la atención primaria. Nuestros resultados quizás podrían ayudar a los gestores a desarrollar políticas públicas que mejoraran el cuidado de salud para las personas con alto riesgo de ECR. El seguimiento a largo plazo de los indicadores de salud que propusimos aquí será útil para evaluar el impacto de la política de intervención.

Inequality in pediatric kidney transplantation in Brazil.

BACKGROUND: The aim of this study was to describe the access and factors associated with kidney transplantation for children in different regions of Brazil. METHODS: We analyzed a cohort of 1211 children enrolled on the transplant list from January 2011 to December of 2013. We fitted regression models to investigate factors associated with: (a) undergoing kidney transplantation from a deceased donor, and (b) being removed from the waiting list. RESULTS: The incidence of transplantation was uneven across regions, with the lowest rate at 0.4 per million age-related population (pmarp) in the Midwest and the highest incidence rate of 8.3 cases pmarp in the South. Children from the North and the Midwest regions had a 3-4 times lower probability of undergoing a deceased donor transplant (p < 0.05). Apart from the geographic region, age of recipients and GDP influenced the outcome. The likelihood of undergoing transplantation was very low in the youngest children in the North and Midwest. The number of transplant centers was not associated with either outcome. CONCLUSIONS: Factors of inequality in transplantation in Brazil are of macroeconomic origin, but there is room to reduce inequalities. Training existing transplant center professionals in the care of children could diminish the discrepancies.

Pediatric Chronic Dialysis in Brazil: Epidemiology and Regional Inequalities.

INTRODUCTION: There are few reports in the literature estimating the epidemiologic characteristics of pediatric chronic dialysis. These patients have impaired physical growth, high number of comorbidities and great need for continuous attention of specialized services with high demand for complex and costly procedures. OBJECTIVE: The aim of this study was to estimate the incidence and prevalence rates and describe the characteristics of children and adolescents undergoing chronic dialysis treatment in a Brazilian demographic health survey. MATERIALS AND METHODS: A cross-sectional study was performed in a representative sample of dialysis centers (nc = 239) that was established from the 2011 Brazilian Nephrology Society Census (Nc = 708). We collected data encompassing the five Brazilian macro-regions. We analyzed the data from all patients under 19 years of age. The sample population consisted of 643 children and adolescents who were on chronic dialysis program anytime in 2012. Data collection was carried out in the dialysis services by means of patients' records reviews and personal interviews with the centers' leaders. RESULTS: We estimated that there were a total of 1,283 pediatric patients on chronic dialysis treatment in Brazil, resulting in a prevalence of 20.0 cases per million age-related population (pmarp) (95% CI: 14.8-25.3) and an incidence of 6.6 cases pmarp in 2012 (95% CI: 4.8-8.4). The South region had the highest prevalence and incidence rates of patients under dialysis therapy, 27.7 (95% CI: 7.3-48.1) and 11.0 (95% CI: 2.8-19.3) cases pmarp, respectively; the lowest prevalence and incidence rates were found in the North-Midwest region, 13.8 (95% CI: 6.2-21.4), and in the Northeast region, 3.8 (95% CI: 1.4-6.3) cases pmarp, respectively. CONCLUSION: Brazil has an overall low prevalence of children on chronic dialysis treatment, figuring near the rates from others countries with same socioeconomic profile. There are substantial differences among regions related to pediatric chronic dialysis treatment. Joint strategies aiming to reduce inequities and improving access to treatment and adequacy of services across the Brazilian regions are necessary to provide an appropriate care setting for this population group.

A cost evaluation of peritoneal dialysis and hemodialysis in the treatment of end-stage renal disease in Sao Paulo, Brazil.

OBJECTIVE: Conventional hemodialysis (HD) predominates over peritoneal dialysis (PD) around the world. Prospective and comparative studies comparing the costs of these modalities are scarce. In the present prospective assessment, we describe the resources used and total patient costs for both HD and PD. ♢ METHODOLOGY: We assessed 249 patients on HD and 228 on PD. All patients were 18 years of age or older and on stable dialysis. The information was collected at three points over 1 year, using standard questionnaires. The sources for costs were the Brazilian public and private health care systems. Societal perspective was considered. ♢ STATISTICAL ANALYSIS: Core trends and dispersions were measured. Regression models assessed the impact of modality on the average total cost per patient per year. ♢ RESULTS: Of the 249 HD patients and 228 PD dialysis patients, 189 (74%) and 160 (70%) respectively completed follow-up. The mean age for women was 55.8 years; for men, it was 59.8 years (p = 0.001). The average total cost per patient-year was US$28 570 for HD and US$27 158 for PD. By category, the costs consisted of direct medical-hospital costs (82.3% for HD, 86.5% for PD), direct nonmedical costs (5.3% for HD, 3.7% for PD), and indirect costs (12.4% for HD, 9.8% for PD). Overall costs were less for PD patients than for their HD counterparts (p = 0.025). ♢ CONCLUSIONS: Maintenance dialysis represented the most important source of costs for both modalities; loss of productivity incurred significant costs. Future studies should contemplate the social consequences arising from each modality.

Health-related quality of life of patients recieving hemodialysis and peritoneal dialysis in São Paulo, Brazil: a longitudinal study.

OBJECTIVES: The aim of this study was to evaluate quality of life in patients undergoing hemodialysis (HD) or peritoneal dialysis (PD) in São Paulo, Brazil. METHODS: Inclusion criteria for this is a 1-year prospective study included being 18 years of age or older and clinically stable receiving chronic dialysis. Quality of life was measured using the SF-12 and the Kidney Disease Quality of Life questionnaires at baseline, 6 months, and 12 months. Patients who completed the surveys for all three periods were evaluated. Differences in quality of life scores were measured using univariate and multivariate regression analyses. RESULTS: One hundred eighty-nine of 249 (76%) HD patients and 161 of 228 (71%) PD patients completed all three surveys. The PD group was older and a larger number had diabetes. PD patients consistently had higher scores than HD patients at all three measurement periods for patient satisfaction (P = 0.002, P = 0.005, and P = 0.005, respectively), encouragement/support from staff (P = 0.003, P = 0.017, and P = 0.029, respectively), and burden of kidney disease (P = 0.003, P = 0.017, and P = 0.057, respectively). The HD group had a greater percent of patients who clinically improved from baseline to 12 months compared to PD patients for sleep quality, social support, encouragement/support from staff, and overall health. Scores for other dimensions of the Kidney Disease Quality of Life and SF-12 questionnaires were not significantly different between the PD and HD groups. CONCLUSIONS: The results provide evidence that PD and HD patients have equivalent health-related quality of life in several domains, although the former performed better in some quality of life domains despite being older and having more comorbidities.

Allocation of initial modality for renal replacement therapy in Brazil.

BACKGROUND AND OBJECTIVES: The use of dialysis modalities for ESRD varies around the world. There is no consensus in literature regarding the most appropriate choice of dialysis method. The aim of this study was to analyze the initial modality for ESRD in Brazil and evaluate the factors determining patients' allocation to either hemodialysis (HD) or peritoneal dialysis (PD). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A retrospective cohort study was performed using national administrative registries of all patients financed by the public system who began renal replacement therapy in 2000 in Brazil. Logistic regression analysis was used to investigate factors associated with the probability of receiving HD or PD at the start of treatment. Independent variables tested were age, sex, presence of diabetes, geographic region of residence, and health care supply indicators. RESULTS: Of 11,563 patients analyzed, 88% started on HD and 12% started on PD. Patients were more likely to be assigned to HD if they were male (odds ratio: 1.44; 95% confidence interval: 1.23 to 1.68) and nondiabetic (odds ratio: 0.71; 95% confidence interval: 0.60 to 0.84). With regard to age, the youngest and the elderly showed lower probability of being in HD. In addition, the state of residence at the start of treatment was very important to explain initial modality allocation. CONCLUSIONS: Our findings suggest that patient allocation in Brazil is not random. The probability of allocation to HD or PD is highly associated with individual attributes and supply variables.

Gaining efficiencies: resources and demand for dialysis around the globe.

OBJECTIVES: End-stage renal disease (ESRD) is a debilitating condition resulting in death unless treated. Treatment options are transplantation and dialysis. Alternative dialysis modalities are peritoneal dialysis (PD) and hemodialysis (HD), each of which has been shown to produce similar outcomes and survival. Nevertheless, the financial implications of each modality are different and these differences vary by country, especially in the developing world. Changes in clinically appropriate dialysis delivery leading to more efficient use of resources would increase the resources available to treat ESRD or other disabling conditions. This article outlines the relative advantages of HD and PD and uses budget impact analysis to estimate the country-specific, 5-year financial implications on total dialysis costs assuming utilization shifts from HD to PD in two high-income (UK, Singapore), three upper-middle-income (Mexico, Chile, Romania), and three lower-middle-income (Thailand, China, Colombia) countries. RESULTS: Peritoneal dialysis is a clinically effective dialysis option that can be significantly cost-saving compared to HD, even in developing countries. CONCLUSIONS: The magnitude of costs associated with treating ESRD patients globally is large and growing. PD is a clinically effective dialysis option that can be used by a majority of ESRD patients and can also be significantly cost-saving compared to HD therapy. Increasing clinically appropriate PD use would substantially reduce health-care costs and help health-care systems meet ever-tightening budget constraints.

Dialysis care, cardiovascular disease, and costs in end-stage renal disease in Brazil.

OBJECTIVES: This study evaluates the cost of dialysis care in Brazil, including costs of ambulatory care and hospital admissions due to all causes and cardiovascular events. METHODS: Data were analyzed for 200 patients with end-stage renal disease (ESRD) on chronic hemodialysis in Brazil between 2001 and 2004. Main end points were all-cause mortality, all-cause hospital admissions, and cardiovascular events. Direct costs of dialysis treatment and complications were computed from the perspective of two payers, the Ministry of Health (MoH) and private health insurance (PHI). RESULTS: Mean number of days of hospitalization was 12 per patient-year. There were 105 cardiovascular events; the most frequent events were coronary disease (n = 59, 56 percent) and congestive heart failure (n = 26, 25 percent). The rate of cardiovascular events was 193 per 1,000 patient-years. There were 43 deaths, and the death rate was 79 per 1,000 patient-years. Median cost per hospital admission was US$ 675 and US$ 932 from the perspective of the MoH and PHI. For admissions due to cardiovascular causes, the corresponding costs were US$ 1,639 and US$ 4,499, respectively. Mean global cost per patient-year for chronic hemodialysis therapy was US$ 7,980 and US$ 13,428 from the perspective of the MoH and PHI, respectively. CONCLUSIONS: Patients on chronic hemodialysis care incur significant healthcare resources due to the costs of dialysis and complications, notably cardiovascular disease. New disease management programs aimed at reducing cardiovascular morbidity and efficient use of resources are critical to ensuring the sustainability of treatments for ESRD in Brazil.

Critical appraisal of published economic evaluations of home care for the elderly.

The goal of the study was to appraise the economic evaluations published between 1980 and 2004 of "home care" for the elderly, focusing on the methodological aspects. MEDLINE was searched to identify and assess economic evaluations (defined as an analysis comparing two or more strategies, involving the assessment of both costs and consequences) related to "home care" exclusively for the elderly (65 years or more) and to critically appraise the methodology using five accepted principles used worldwide for conducting economic evaluations. Twenty-four economic evaluations of "home care" for the elderly were identified and the articles were assessed. All five principles were satisfactorily addressed in two studies (8.3%), four principles in four studies (16.7%), three principles in five studies (20.8%), two principles in eight studies (33.3%) and only one principle in five studies (20.8%). A disparity in the methodology of writing economic evaluations compromises the comparisons among outcomes and lately jeopardizes decisions on the choice of the most appropriate healthcare interventions. The methodological principles represent important guidelines but the discussion of the context of the economic evaluation and the special characteristics of some services and populations should be considered for the appropriate use of economic evaluations.

[Critical appraisal of sevelamer for the treatment of hyperphosphatemia in patients with chronic renal failure]. / Avaliação crítica do sevelamer no tratamento da hiperfosfatemia em pacientes com insuficiência renal crônica.

OBJECTIVE: To evaluate in patients with chronic renal failure (CRF) the effectiveness and the costs of sevelamer, a cationic polymer calcium- and aluminum-free, that is a new gastrointestinal phosphate binder. METHODS: Literature review and critical appraisal of six clinical trials about the effectiveness and two economic studies of sevelamer in CRF patients. RESULTS: Sevelamer is an effective phosphate binder (used in a mean daily dose of 3.5 g three times per day with meals) and with similar effect as that obtained with calcium salts, without the adverse manifestations of the latter (elevation of calcium x phosphorus product, hypercalcemia, vascular and cardiac calcifications, etc.). Moreover, sevelamer reduced serum LDL cholesterol in around 30%. Despite the greater direct costs of sevelamer compared with calcium salts, the total costs may be lower due to the reduction of costs with clinical complications and hospitalizations. CONCLUSIONS: Sevelamer has important therapeutic value in CRF patients with hyperphosphatemia. Economic analyses should be performed in our setting to define the cost-effectiveness relationship of sevelamer.

Effectiveness and costs of chemical versus electrical cardioversion of atrial fibrillation.

BACKGROUND: Atrial fibrillation is the most common sustained cardiac arrhythmia and has an important impact on costs of medical assistance. Traditional interventions to convert atrial fibrillation to sinus rhythm are antiarrhythmic drugs and external electrical cardioversion. However, the best option for starting the cardioversion is not well established. METHODS: In a multicentre randomised trial of 139 patients with persistent atrial fibrillation lasting less than 6 months, we compared the effectiveness and the cost-effectiveness ratio of initial treatment with chemical or electrical cardioversion. Subjects who did not achieve sinus rhythm with chemical cardioversion were considered to undergo electrical cardioversion and vice-versa. RESULTS: The efficacy of the initial attempt for cardioversion was similar with chemical or electrical cardioversion (74 vs. 73%, P=0.95). However, the strategy of starting with antiarrhythmic drugs was more effective than with electrical procedure (96 vs. 84%, P=0.0016). Initiating with chemical cardioversion was also less expensive than with electrical cardioversion (1240 US dollars vs. 1917 US dollars ; P=0.002). Life-threatening complications occurred only during chemical cardioversion (5%), all of them in patients with structural heart disease. CONCLUSIONS: In patients with persistent atrial fibrillation of less than 6 months, initial chemical or electrical cardioversion appear to be similar but the strategy of starting the cardioversion with antiarrhythmic drugs is more effective and less expensive than starting with the electrical procedure. Patients with structural heart disease undergoing chemical cardioversion seem to be more susceptible to severe complications.

Avaliaçäo crítica do sevelamer no tratamento da hiperfosfatemia em pacientes com insuficiência renal crônica / Critical appraisal of sevelamer for the treatment of hyperphosphatemia in patients with chronic renal failure

OBJETIVO: Avaliar em pacientes com insuficiência renal crônica (IRC), a efetividade e os custos do sevelamer, um polímero catiônico livre de alumínio e cálcio, que é um novo quelante de fósforo no trato gastrointestinal. MÉTODOS: Revisäo da literatura e avaliaçäo crítica de seis ensaios clínicos publicados sobre efetividade e duas avaliações econômicas do sevelamer em pacientes com IRC. RESULTADOS: O sevelamer é um quelante de fosfato efetivo (utilizado na dose média de 3,5g/dia dividido em 3 doses às refeições) e com efeito similar ao obtido com sais de cálcio, além de näo apresentar os efeitos colaterais destes últimos (elevaçäo do produto cálcio x fósforo, hipercalcemia, calcificaçäo vascular, musculo-esquelética e cardíaca, etc.). Além disso, o sevelamer promove reduçäo em cerca de 30 por cento nos níveis de LDL colesterol. Custos diretos do sevelamer säo maiores que os dos sais de cálcio, embora os custos totais possam ser menores devido a menor taxa de complicações clínicas e hospitalizações. CONCLUSÕES: Sevelamer agrega valor terapêutico importante em pacientes com IRC e hiperfosfatemia. Estudos fármaco-econômicos devem ser realizados em nosso meio para se avaliar a relaçäo custo-efetividade do uso do sevelamer

[Translation and cultural adaptation of the quality of life assessment instrument for chronic renal patients (KDQOL-SF)]. / Tradução e adaptação cultural do instrumento de avaliação de qualidade de vida para pacientes renais crônicos (KDQOL-SF).

BACKGROUND: The objective of this study was to translate from English into Portuguese and to perform cultural adaptation of the Kidney Disease Quality of Life Short Form--KDQOL-SF to make possible its validation in Brazil. METHODS: This instrument was translated from the original English version into Portuguese language by the authors and it was also translated by a certified translator and revised by a specialized translator who evaluated the level of difficulty for translation. Thirty end-stage renal disease patients undergoing dialysis were randomly selected to participate in the study. RESULTS: The mean age of patients was 47 +/- 9 years (23 to 60 yr), and the predominant education level was incomplete elementary school (1st to 8th grade=53%); 60% of the patients were female. The majority of patients (63%) were undergoing hemodialysis and the period of treatment within the last 30 days was 12 hours or more per week. The time of dialysis treatment was 0-2 years for 70% of the patients. The feasibility of the instrument and the difficulties found by the patients were evaluated by a panel of experts and changes were made regarding difficulties of comprehension. Some activities were substituted since they were not regular for the Brazilian population. There were modifications in expressions of translation for terms suggested by patients and Brazilian experts and, for five items it was suggested to include an explanation in parentheses. Common words used in the Portuguese language were chosen. CONCLUSIONS: The translation and cross-cultural adaptation of the KDQOL questionnaire to Portuguese were concluded, having been accomplished this important stage for its validation and use in our environment.

Tradução e adaptação cultural do instrumento de avaliação de qualidade de vida para pacientes renais crônicos (KDQOL-SF TM) / Translation and cultural adaptation of the quality of life assessment instrument for chronic renal patients (KDQOL-SF TM)

OBJETIVO: Realizar a tradução para o português e a adaptação cultural do instrumento Kidney Disease Quality of Life Short Form - KDQOL-SF TM para sua posterior validação no Brasil. MÉTODOS: O instrumento foi traduzido da versão original (Inglês) para a língua portuguesa pelos autores e por tradutor juramentado e, posteriormente, revisado e avaliado quanto ao grau de dificuldade das traduções e equivalência por tradutor especialista. O instrumento foi, então, aplicado em 30 pacientes com insuficiência renal crônica terminal, em tratamento dialítico, selecionados aleatoriamente. RESULTADOS: A idade média dos pacientes foi 47±9 anos (variação, 23 a 60 anos), com escolaridade básica incompleta em 53 por cento deles, sendo 60 por cento do sexo feminino. A maioria dos pacientes (63 por cento) realizava hemodiálise e o período de tratamento nos 30 dias antecedentes à aplicação do questionário foi de pelo menos 12 horas ou mais por semana. O tempo de tratamento dialítico era de 0-2 anos para 70 por cento dos pacientes. A viabilidade do instrumento e as dificuldades encontradas pelos pacientes foram avaliadas por um painel de profissionais e as mudanças foram feitas baseadas nas dificuldades de compreensão. As atividades do instrumento original incompatíveis com atividades realizadas habitualmente pela população brasileira foram substituídas. Foram modificadas expressões da tradução, por termos sugeridos pelos pacientes e especialistas brasileiros e a explicação de cinco itens foi colocada entre parênteses para facilitar a compreensão. As palavras de uso comum da língua portuguesa foram mantidas. CONCLUSÃO: A tradução e a adaptação cultural do questionário KDQOL-SF para o português foram realizadas, tendo sido cumprida esta importante etapa para sua validação e utilização em nosso meio

Burden and quality of life of caregivers for hemodialysis patients.

The aim of this study is to describe the characteristics of caregivers of chronic hemodialysis patients, assess their perceived burden and health-related quality of life, and investigate factors influencing this burden. We studied 100 hemodialysis patients and their respective primary caregivers for more than 4 months, measuring quality of life by the Medical Outcomes Survey 36-Item Short-Form Health Survey (SF-36). Subjective burden on caregivers was assessed by the Caregiver Burden scale (score range, 1 to 4; higher values indicate a greater effect). The majority of caregivers were women (84%), married (66%), with a mean age of 46 +/- 2 (SE) years, and of low socioeconomic level. Their main types of relationship with patients were wives (38%) and sons or daughters (27%). Caregiver Mental Health and Vitality were the most affected emotional dimensions on the SF-36 (mean scores, 64.4 +/- 1.8 and 66.6 +/- 1.7, respectively). Mean score of total burden experienced was 2.07 +/- 0.05. Multiple regression analysis showed that independent and significant predictors of burden were Mental Health of the caregiver (R2 = 24%), Vitality of the patient (R2 = 10%), type of relationship of the caregiver (female spouse) (R2 = 5%), and Pain of the caregiver (R2 = 3%). Caregivers of hemodialysis patients may experience a significant burden and an adverse effect on their quality of life. Emotional aspects of caregivers (particularly female spouses) and patients are important predictors of burden. Social support and psychological interventions should be considered to improve caregiver life and patient outcomes.

Custo-efetividade do tratamento da insuficiência renal crônica terminal no Brasil / Cost benefit in the treatment of terminal chronic renal insufficiency in Brazil

Analisamos a relaçäo custo-efetividade do tratamento da insuficiência renal crônica terminal comparando os seguintes procedimentos: hemodiálise (HD), diálise peritoneal ambulatorial contínua (CAPD), transplante (TX) com doador vivo (VI) e com doador cadáver (CD). Foram estudados, retrospectivamente, 130 pacientes näo diabéticos, com idade variando de 15 a 50 anos, os quais iniciaram tratamento para insuficiência renal crônica terminal entre 1983 e 1985, na Escola Paulista de Medicina. Entre os pacientes estudados, 50 submeteram-se a HD, 30 a CAPD, 36 a TX-VI e 14 a TX-CD. Custos diretos e induzidos foram computados do ponto de vista do INAMPS. Ao final do 1§ ano, o custo ao INAMPS por ano de vida ganho para CAPD, HD, TX-CD E TX-VI foi respectivamente, em cruzados (Cz$):173.495,40, 150.732,00, 100.123,80 e 53.186,00; a sobrevida atuarial dos pacientes foi, percentualmente: 89,5, 100,0, 69,8 e 91,6. Análise de sensibilidade para custos do transplante renal (TX-VI e TX-CD), considerando a inclusäo dos custos dos testes de histocompatibilidade e dos honorários médicos de acordo com a tabela da Associaçäo Médica Brasileira, näo demonstrou alteraçäo significante nos resultados finais. Assumindo-se a sobrevida e da técnica e de pacientes de acordo com a literatura internacional e usando-se os custos em nosso meio, ao final do 2ª ano, a CAPD e a HD tiveram custo estimado equivalente. Este valor foi significantemente superior ao TX-VI ou TX-CD, quer se utilize imunossupressäo convencional, quer se utilize imunossupressäo convencional, quer se utilize a ciclosporina. Esta análise fornece dados que podem auxiliar na decisäo médico-política concernente ao tratamento da insuficiência renal crônica terminal no nosso meio