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.

Medical students' and health professionals' knowledge regarding acute kidney injury: a cross-sectional study in the city of São Paulo, Brazil.

BACKGROUND: Acute kidney injury (AKI) is a worldwide public health problem and is often treated by non-nephrologists. The objective of this study was to evaluate the knowledge of non-nephrologists, undergraduate medical students and health professionals regarding AKI. METHODS: An unsupervised and closed-response electronic questionnaire was sent to sixth-year medical students and non-nephrologist health professionals working in the city of São Paulo, Brazil. RESULTS: A total of 424 responses were returned from 650 invitations (40.1% males, 39.2% physicians, 34.0% senior medical students or resident physicians, 16.3% nurses and 10.6% pharmacists). The knowledge of medical students and health professionals about the prevalence and lethality of AKI in hospitals ranged from 40.8% to 59.2%. The most recognized susceptibilities and risk factors for AKI were sepsis/septic shock (95.0%) and diabetes mellitus (91.3%); the less-recognized susceptibilities and risk factors were exposure to gadolinium-based contrast (23.3%) and chronic liver disease (55.7%). The study participants' rate of knowledge regarding the diagnosis of AKI was 50.9-73.6%, and their rate of knowledge regarding the criteria of increased serum creatinine and reduced urine volume was 52.6%. The most-recognized nephrotoxic medications were vancomycin (82.3%) and diclofenac (80.4%), and the least-recognized were acyclovir (34.0%) and cotrimoxazole (30.4%). The indications for emergency renal replacement therapy that were recognized by the study respondents were metabolic acidosis (82.3%), uremic syndrome (81.6%), hyperkalemia unresponsive to clinical treatment (78.1%) and acute pulmonary edema (71.6%). CONCLUSION: The study showed knowledge gaps that can impact patient care and can be used to guide professional training programs.

The Effect of Long-Term Cholecalciferol Supplementation on Vascular Calcification in Chronic Kidney Disease Patients With Hypovitaminosis D.

OBJECTIVE: The role of vitamin D supplementation on vascular calcification (VC) in patients with chronic kidney disease (CKD) is controversial. The objective of this study was to evaluate the effects of long-term cholecalciferol supplementation on VC in nondialysis patients with CKD stages 3-4 with hypovitaminosis D. DESIGN AND METHODS: Eighty patients aged 18-85 years with creatinine clearance between 15 and 60 mL/min/1.73 m2 and serum 25(OH)D level < 30 ng/mL were enrolled in a 18-month prospective study. Individuals with vitamin D insufficiency (25-hydroxyvitamin D [25(OH)D] level between 16 and 29 ng/mL) were included in a randomized, double-blind, two-arm study to receive cholecalciferol or placebo. Patients with vitamin D deficiency [25(OH)D < 15 ng/mL] were included in an observational study and mandatorily received cholecalciferol. The coronary artery calcium score was obtained by multislice computed tomography at baseline and the 18th month. RESULTS: During the study, VC did not change in the treated insufficient group (418 [81-611] to 364 [232-817] AU, P = 0.25) but increased in the placebo group (118 [37-421] to 199 [49-490] AU, P = 0.01). The calcium score change was inversely correlated with 25(OH)D change (r = -0.45; P = 0.037) in the treated insufficient group but not in the placebo group. Renal function did not change in the insufficient, treated, and placebo groups. In multivariate analysis, there was no difference in VC progression between the treated and placebo insufficient groups (interaction P = 0.92). In the deficient group, VC progressed (265 [84-733] to 333 [157-745] AU; P = 0.006) and renal function declined (33 [26-43] to 23 [17-49] mL/min/1.73 m2; P = 0.04). The calcium score change was inversely correlated with cholecalciferol cumulative doses (r = -0.41; P = 0.048) and kidney function change (r = -0.43; P = 0.033) but not with 25(OH)D change (r = -0.08; P = 0.69). CONCLUSION: Vitamin D supplementation did not attenuate VC progression in CKD patients with hypovitaminosis D. CONCLUSION: Vitamin D supplementation did not attenuate VC progression in CKD patients with hypovitaminosis D.

Privatization and Oligopolies of the Renal Replacement Therapy Sector on Contemporary Capitalism: A Systematic Review and the Brazilian Scenario.

Worldwide the assistance on renal replacement therapy (RRT) is carried out mainly by private for-profit services and in a market with increase in mergers and acquisitions. The aim of this study was to conduct an integrative systematic review on privatization and oligopolies in the RRT sector in the context of contemporary capitalism. The inclusion criteria were scientific articles without language restrictions and that addressed the themes of oligopoly or privatization of RRT market. Studies published before 1990 were excluded. The exploratory search for publications was carried out on February 13, 2024 on the Virtual Health Library Regional Portal (VHL). Using the step-by-step of PRISMA flowchart, 34 articles were retrieved, of which 31 addressed the RRT sector in the United States and 26 compared for-profit dialysis units or those belonging to large organizations with non-profit or public ones. The main effects of privatization and oligopolies, evaluated by the studies, were: mortality, hospitalization, use of peritoneal dialysis and registration for kidney transplantation. When considering these outcomes, 19 (73%) articles showed worse results in private units or those belonging to large organizations, six (23%) studies were in favor of privatization or oligopolies and one study was neutral (4%). In summary, most of the articles included in this systematic review showed deleterious effects of oligopolization and privatization of the RRT sector on the patients served. Possible explanations for this result could be the presence of conflicts of interest in the RRT sector and the lack of incentive to implement the chronic kidney disease care line. The predominance of articles from a single nation may suggest that few countries have transparent mechanisms to monitor the quality of care and outcomes of patients on chronic dialysis.

Epidemiology of acute kidney injury in the clinical emergency: A prospective cohort study at a high-complexity public university hospital in São Paulo, Brazil.

INTRODUCTION: Southern Hemisphere countries have been underrepresented in epidemiological studies on acute kidney injury (AKI). The objectives of this study were to determine the frequency, risk factors, and outcomes of AKI in adult hospitalized patients from the emergency department of a public high-complexity teaching hospital in the city of São Paulo, Brazil. METHODS: Observational and prospective study. AKI was defined by the KDIGO guidelines (Kidney Disease: Improving Global Outcomes) using only serum creatinine. RESULTS: Among the 731 patients studied (age: median 61 years, IQR 47-72 years; 55% male), 48% had hypertension and 28% had diabetes as comorbidities. The frequency of AKI was 52.1% (25.9% community-based AKI [C-AKI] and 26.3% hospital-acquired AKI [H-AKI]). Dehydration, hypotension, and edema were found in 29%, 15%, and 15% of participants, respectively, at hospital admission. The in-hospital and 12-month mortality rates of patients with vs. without AKI were 25.2% vs. 11.1% (p<0.001) and 36.7% vs. 12.9% (p<0.001), respectively. The independent risk factors for C-AKI were chronic kidney disease (CKD), chronic liver disease, age, and hospitalization for cardiovascular disease. Those for H-AKI were CKD, heart failure as comorbidities, hypotension, and edema at hospital admission. H-AKI was an independent risk factor for death in the hospital, but not at 12 months. C-AKI was not a risk factor for death. CONCLUSIONS: AKI occurred in more than half of the admissions to the clinical emergency department of the hospital and was equally distributed between C-AKI and H-AKI. Many patients had correctable risk factors for AKI, such as dehydration and arterial hypotension (44%) at admission. The only independent risk factor for both C-AKI and H-AKI was CKD as comorbidity.

A Cross-Sectional Study on the Prevalence and Risk Stratification of Chronic Kidney Disease in Cardiological Patients in São Paulo, Brazil.

Chronic kidney disease (CKD) provides a worse prognosis for patients with heart disease. In Latin America, studies that analyzed the prevalence and risk stratification of CKD in this population are scarce. We aimed to evaluate CKD prevalence and risk categories in patients of a public referral cardiology hospital in São Paulo, Brazil. This was a cross-sectional study based on a laboratory database. Outpatient serum creatinine and proteinuria results performed between 1 January 2021 and 31 December 2021 were analyzed. CKD was defined by estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 and proteinuria, by the albumin/creatinine ratio in a spot urine sample (UACR) >30 mg/g. A total of 36,651 adults were identified with serum creatinine levels (median age 72.4 [IQR, 51.0-73.6] years, 51% male). Among them, 51.9% had UACR dosage (71.5% with UACR < 30 mg/g, 22.6%, between 30-300 mg/g, and 5.9% with UACR > 300 mg/g). The prevalence of CKD was 30.9% (15.3% stage 3a, 10.2% stage 3b, 3.6% stage 4, and 1.7% stage 5), and the distribution of patients in the risk categories of the disease was: 52.0% with low-risk, 23.5%, moderate risk, 13.0%, high risk, and 11.2%, very high. In an outpatient setting, the prevalence of CKD in cardiological patients was almost three times (31%) that of the general population; about half of the individuals evaluated (48%) were not screened for an important risk marker (proteinuria), and approximately a quarter of these patients (24%) were in the high or very high CKD risk categories.

Critically ill patients with COVID-19-associated acute kidney injury treated with kidney replacement therapy: Comparison between the first and second pandemic waves in São Paulo, Brazil.

INTRODUCTION: This study aimed to compare the characteristics and outcomes of critically ill patients with COVID-19-associated acute kidney injury (AKI) who were treated with kidney replacement therapy (KRT) in the first and second waves of the pandemic in the megalopolis of Sao Paulo, Brazil. METHODS: A multicenter retrospective study was conducted in 10 intensive care units (ICUs). Patients aged ≥18 years, and treated with KRT due to COVID-19-associated AKI were included. We compared demographic, laboratory and clinical data, KRT parameters and patient outcomes in the first and second COVID-19 waves. RESULTS: We assessed 656 patients (327 in the first wave and 329 in the second one). Second-wave patients were admitted later (7.1±5.0 vs. 5.6±3.9 days after the onset of symptoms, p<0.001), were younger (61.4±13.7 vs. 63.8±13.6 years, p = 0.023), had a lower frequency of diabetes (37.1% vs. 47.1%, p = 0.009) and obesity (29.5% vs. 40.0%, p = 0.007), had a greater need for vasopressors (93.3% vs. 84.6%, p<0.001) and mechanical ventilation (95.7% vs. 87.8%, p<0.001), and had higher lethality (84.8% vs. 72.7%, p<0.001) than first-wave patients. KRT quality markers were independently associated with a reduction in the OR for death in both pandemic waves. CONCLUSIONS: In the Sao Paulo megalopolis, the lethality of critically ill patients with COVID-19-associated AKI treated with KRT was higher in the second wave of the pandemic, despite these patients being younger and having fewer comorbidities. Potential factors related to this poor outcome were difficulties in health care access, lack of intra-hospital resources, delay vaccination and virus variants.

The first appointment with a nephrologist: Brazilian patients' demographic and kidney function characteristics. A retrospective study.

BACKGROUND: The number of nephrologists has risen slowly, compared with the prevalence of chronic kidney disease (CKD) in Brazil. Data on patients referred to nephrology outpatient clinics remains scarce. OBJECTIVE: To determine the demographic and kidney function characteristics of patients at their first appointment with a nephrologist. DESIGN AND SETTING: Retrospective study conducted at three nephrology outpatient clinics (public and private services), in São Paulo, Brazil. METHODS: From December 2019 to February 2020, we collected patient data regarding demographics, kidney function parameters and comorbidities. We then analyzed data on 394 patients who met a nephrologist for their first appointment. RESULTS: The main comorbidities were hypertension (63.7%), diabetes (33.5%) and nephrolithiasis (22.3%). Regarding CKD stages, 24.1%, 9.1%, 13.7%, 15.2%, 15.2% and 2.3% of the patients were in stages 1, 2, 3a, 3b, 4 and 5, respectively. Proteinuria was absent or mild, moderate and high in 17.3%, 15.2% and 11.7%, respectively; and 16.2% had not undergone previous investigation of serum creatinine or proteinuria (55.8%). For 17.5%, referral to a nephrologist occurred late. Patients in public services were older than those in private services (59 years versus 51 years, respectively; P = 0.001), more frequently hypertensive (69.7% versus 57.5%; P = 0.01) and reached a nephrologist later (22.4% versus 12.4%; P = 0.009). CONCLUSION: Referrals to a nephrologist were not being made using any guidelines for CKD risk and many cases could have been managed within primary care. Late referral to a nephrologist happened in one-fifth of the cases and more frequently in the public service.

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.

Quality indicators for primary health care in chronic kidney disease in the public service of a city in the State of São Paulo, Brazil.

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.

COVID-19-associated acute kidney injury patients treated with renal replacement therapy in the intensive care unit: A multicenter study in São Paulo, Brazil.

INTRODUCTION: Multicenter studies involving patients with acute kidney injury (AKI) associated with the disease caused by the new coronavirus (COVID-19) and treated with renal replacement therapy (RRT) in developing countries are scarce. The objectives of this study were to evaluate the demographic profile, clinical picture, risk factors for mortality, and outcomes of critically ill patients with AKI requiring dialysis (AKI-RRT) and with COVID-19 in the megalopolis of São Paulo, Brazil. METHODS: This multicenter, retrospective, observational study was conducted in the intensive care units of 13 public and private hospitals in the metropolitan region of the municipality of São Paulo. Patients hospitalized in an intensive care unit, aged ≥ 18 years, and treated with RRT due to COVID-19-associated AKI were included. RESULTS: The study group consisted of 375 patients (age 64.1 years, 68.8% male). Most (62.1%) had two or more comorbidities: 68.8%, arterial hypertension; 45.3%, diabetes; 36.3%, anemia; 30.9%, obesity; 18.7%, chronic kidney disease; 15.7%, coronary artery disease; 10.4%, heart failure; and 8.5%, chronic obstructive pulmonary disease. Death occurred in 72.5% of the study population (272 patients). Among the 103 survivors, 22.3% (23 patients) were discharged on RRT. In a multiple regression analysis, the independent factors associated with death were the number of organ dysfunctions at admission and RRT efficiency. CONCLUSION: AKI-RRT associated with COVID-19 occurred in patients with an elevated burden of comorbidities and was associated with high mortality (72.5%). The number of organ dysfunctions during hospitalization and RRT efficiency were independent factors associated with mortality. A meaningful portion of survivors was discharged while dependent on RRT (22.3%).

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.

The first appointment with a nephrologist: Brazilian patients' demographic and kidney function characteristics. A retrospective study

ABSTRACT BACKGROUND: The number of nephrologists has risen slowly, compared with the prevalence of chronic kidney disease (CKD) in Brazil. Data on patients referred to nephrology outpatient clinics remains scarce. OBJECTIVE: To determine the demographic and kidney function characteristics of patients at their first appointment with a nephrologist. DESIGN AND SETTING: Retrospective study conducted at three nephrology outpatient clinics (public and private services), in São Paulo, Brazil. METHODS: From December 2019 to February 2020, we collected patient data regarding demographics, kidney function parameters and comorbidities. We then analyzed data on 394 patients who met a nephrologist for their first appointment. RESULTS: The main comorbidities were hypertension (63.7%), diabetes (33.5%) and nephrolithiasis (22.3%). Regarding CKD stages, 24.1%, 9.1%, 13.7%, 15.2%, 15.2% and 2.3% of the patients were in stages 1, 2, 3a, 3b, 4 and 5, respectively. Proteinuria was absent or mild, moderate and high in 17.3%, 15.2% and 11.7%, respectively; and 16.2% had not undergone previous investigation of serum creatinine or proteinuria (55.8%). For 17.5%, referral to a nephrologist occurred late. Patients in public services were older than those in private services (59 years versus 51 years, respectively; P = 0.001), more frequently hypertensive (69.7% versus 57.5%; P = 0.01) and reached a nephrologist later (22.4% versus 12.4%; P = 0.009). CONCLUSION: Referrals to a nephrologist were not being made using any guidelines for CKD risk and many cases could have been managed within primary care. Late referral to a nephrologist happened in one-fifth of the cases and more frequently in the public service.

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.