Uma comparação dos custos do transplante renal em relação às diálises no Brasil

Challenges to establishing and maintaining kidney transplantation programs in developing countries: What are the coping strategies?

Kidney transplantation (KT) is the optimal form of renal replacement therapy for patients with end-stage renal diseases. However, this health service is not available to all patients, especially in developing countries. The deceased donor KT programs are mostly absent, and the living donor KT centers are scarce. Single-center studies presenting experiences from developing countries usually report a variety of challenges. This review addresses these challenges and the opposing strategies by reviewing the single-center experiences of developing countries. The financial challenges hamper the infrastructural and material availability, coverage of transplant costs, and qualification of medical personnel. The sociocultural challenges influence organ donation, equity of beneficence, and regular follow-up work. Low interests and motives for transplantation may result from high medicolegal responsibilities in KT practice, intense potential psychosocial burdens, complex qualification protocols, and low productivity or compensation for KT practice. Low medical literacy about KT advantages is prevalent among clinicians, patients, and the public. The inefficient organizational and regulatory oversight is translated into inefficient healthcare systems, absent national KT programs and registries, uncoordinated job descriptions and qualification protocols, uncoordinated on-site investigations with regulatory constraints, and the prevalence of commercial KT practices. These challenges resulted in noticeable differences between KT services in developed and developing countries. The coping strategies can be summarized in two main mechanisms: The first mechanism is maximizing the available resources by increasing the rates of living kidney donation, promoting the expertise of medical personnel, reducing material consumption, and supporting the establishment and maintenance of KT programs. The latter warrants the expansion of the public sector and the elimination of non-ethical KT practices. The second mechanism is recruiting external resources, including financial, experience, and training agreements.

Influence of HLA-A, B, and -DRB1 genes and panel-reactive antibodies on the waitlist time for kidney transplantation in the state of Sao Paulo-Brazil

BACKGROUND

Brazil ranks second in the absolute number of transplants. However, the supply remains insufficient to meet the demands, resulting in a lengthy waitlist. This study aimed to analyze whether the frequency of human leukocyte antigen (HLA) and the value of calculated panel reactive antibody (cPRA) would influence the waiting time for kidney transplantation.

METHODS

The HLA-A, B, and -DRB1 frequencies and the cPRA value were analyzed in 11,186 kidney transplant candidates included in the waitlist from 2006 to 2016.

RESULTS

The most frequent alleles were HLA-A*02, HLA-B*35, and HLA-DRB1*13. The overall mean length of stay on the list was 986 ± 1001 days. The mean waiting time for the three most frequent alleles of the HLA-A and B loci showed no significant difference when compared with the least frequent alleles; however, for the HLA-DRB1 locus, the most frequent alleles showed a shorter waiting time. In the association between HLA and PRA, the average length of stay on the list increased according to the candidate's degree of sensitization, regardless of the analyzed HLA frequency.

CONCLUSION

The length of stay on the waitlist is influenced by the frequency of the HLA alleles of the DRB1 locus and the degree of sensitization.

Mesenchymal Stromal Cell Therapy Reverses Detrusor Hypoactivity in a Chronic Kidney Patient

Detrusor hypoactivity (DH) is characterized by low detrusor pressure or a short contraction associated with low urinary flow. This condition can progress to chronic renal failure (CRF) and result in the need for dialysis. The present case report demonstrates that a patient diagnosed with DH and CRF who received two transplants with 2 × 10⁶ autologous mesenchymal stromal cells at an interval of 30 days recovered the contractile strength of the bladder and normalized his renal function. The patient had a score of 19 on the ICIQ-SF before cell therapy, and that score was reduced to 1 after transplantation. These results demonstrate that there was an improvement in his voiding function, urinary stream and urine volume as evaluated by urofluxometry. In addition, a urodynamic study carried out after treatment showed an increase in the maximum flow from 2 mL/s to 23 mL/s, the detrusor pressure in the maximum flow from 21 cm H₂O to 46 cm H₂O and a BCI that went from 31 to 161, characterizing good detrusor contraction. Thus, in the present case, the transplantation of autologous mesenchymal stromal cells proved to be a viable therapeutic option to allow the patient to recover the contractile strength of the bladder, and reversed the CRF.

A Statistical Prediction Model for Survival After Kidney Transplantation from Deceased Donors

Background

In an environment of limited kidney donation resources, patient recovery and survival after kidney transplantation (KT) are highly important. We used pre-operative data of kidney recipients to build a statistical model for predicting survivability after kidney transplantation.

Material/Methods

A dataset was constructed from a pool of patients who received a first KT in our hospital. For allogeneic transplantation, all donated kidneys were collected from deceased donors. Logistic regression analysis was used to change continuous variables into dichotomous ones through the creation of appropriate cut-off values. A regression model based on the least absolute shrinkage and selection operator (LASSO) algorithm was used for dimensionality reduction, feature selection, and survivability prediction. We used receiver operating characteristic (ROC) analysis, calibration, and decision curve analysis (DCA) to evaluate the performance and clinical impact of the proposed model. Finally, a 10-fold cross-validation scheme was implemented to verify the model robustness.

Results

We identified 22 potential variables from which 30 features were selected as survivability predictors. The model established based on the LASSO regression algorithm had shown discrimination with an area under curve (AUC) value of 0.690 (95% confidence interval: 0.557–0.823) and good calibration result. DCA demonstrated clinical applicability of the prognostic model when the intervention progressed to the possibility threshold of 2%. An average AUC value of 0.691 was obtained on the validation data.

Conclusions

Our results suggest that the proposed model can predict the mortality risk for patients after kidney transplants and could help kidney specialists choose kidney recipients with better prognosis.

Risk factors for colonization and infection by resistant microorganisms in kidney transplant recipients

OBJECTIVES

to assess the prevalence of colonization and infection by multidrug-resistant bacteria in patients undergoing kidney transplantation and identify the rate of infection, morbidity and mortality and associated risk factors.

METHODS

a prospective cohort of 200 randomly included kidney transplant recipients. Epidemiological surveillance of the studied microorganisms was carried out in the first 24 hours and 7 days after transplantation.

RESULTS

ninety (45%) patients were considered colonized. Female sex, hypertension and diabetes (p<0.005), dialysis time (p<0.004), length of stay after transplantation, delayed renal function, and length of stay were identified as risk factors. The microorganisms were isolated from surgical site, bloodstream and urinary tract infections.

CONCLUSIONS

colonization by resistant microorganisms in kidney transplant patients was frequent and risk factors associated with infection were identified. The results should guide the care team in order to minimize morbidity and mortality related to infectious causes in this population.

[Prevalence and factors associated with non-enrollment for kidney transplant]

This study evaluated the prevalence and factors associated with lack of enrollment for kidney transplant among patients in chronic dialysis in Greater Metropolitan Fortaleza, Ceará, Brazil. The sample excluded patients with insufficient clinical status and those already in pre-kidney transplant evaluation. A semi-structured questionnaire was applied, including options for the question, "What is the main reason why you are not enrolled for kidney transplant?" Prevalence of patients considered fit but not enrolled or in pre- kidney transplant evaluation was 50.7%. The main reasons were fear of failure/loss of grafting (32.5%), difficulty with transportation or access to tests (20.9%), and temporary personal or family problems (13.7%). In the multivariate analysis, the variables associated with fear of failure or loss of graft were female sex (OR = 1.763; 95%CI: 1.224-2.540) and end-stage renal disease (ESRD) due to hypertension (OR = 1.732; 95%CI: 1.178-2.547), while monthly income (number of minimum wages) showed a protective association (OR = 0.882; 95%CI: 0.785-0.991). Time on dialysis (months) was a risk factor for difficulty with transportation and access to tests (OR = 1.004; 95%CI: 1.001-1.007), and female sex showed a protective association (OR = 0.576; 95%CI: 0.368-0.901). These results show high prevalence of patients in dialysis not enrolled on the kidney transplant waitlist. The main causes were lack of information and lack of access. Female sex, low income, and ESRD due to hypertension were risk factors for lack of enrollment on the kidney transplant waitlist due to fear of loss of graft, resulting from lack of information on this treatment modality. Male sex and longer time on dialysis were risk factors for difficulty in access to kidney transplant.

Quality of life of individuals receiving kidney transplantation in Amazonas State

OBJECTIVE

to analyze the quality of life of kidney transplant receivers in the State of Amazonas.

METHOD

a cross-sectional, descriptive study, performed with 222 individuals after renal transplantation registered in a private clinic and in a health public ambulatory. Data collection took place through structured interviews where the quality of life was measured by the Kidney Disease Quality of Life - Short Form. Descriptive statistics were used for data analysis.

RESULTS

the quality of life scores found ranged from 36.5 to 83.1. The quality of life domains, specifics of renal disease, have proved to be superior to generic ones. The most compromised were work situation; sleep; physical function and emotional function, with scores of 36.5; 53.7; 52.4; 55.1, respectively, and correlated moderately and significantly with each other.

CONCLUSION

the majority (63.2%) of the quality of life domains obtained high scores and the specific component of renal disease had higher scores than the generic component.

Relationship between quality of life, self-esteem and depression in people after kidney transplantation

OBJECTIVE

to assess the relationship between health-related quality of life with depression and self-esteem of people after kidney transplantation.

METHOD

a cross-sectional study of 47 outpatients from October 2016 to February 2017. The following tools were applied: The Medical Outcomes Study 36-Item Short-Form Health Survey, Beck Depression Inventory and Rosenberg Self-Esteem Scale. Descriptive statistics and Spearman correlation were used.

RESULTS

women had lower scores for health-related quality of life. Young adults, people with up to one and a half years of transplantation and those who had dialysis for more than one year had higher scores.

CONCLUSION

the health-related quality of life of people with chronic kidney disease after transplantation ranged from good to excellent. The presence of depression was not identified. The relationship of data indicates that the higher the quality of life, the better the self-esteem assessment.

Cost and Factors Associated With the Hospitalization of Patients Undergoing Heart Transplantation

OBJECTIVES

The aim of the study was to describe the cost and factors associated with the hospitalization of patients undergoing heart transplantation.

METHODS

A cross-sectional, descriptive study with a quantitative approach developed at an important heart transplant center in southern Brazil. Twenty patients who had undergone transplantation during the period 2007 to 2016 were included in the study. Central tendency measures and values presented as mean ± SD or median and quartiles were calculated. Multiple linear regression was performed to verify the variables that interfered with the cost.

RESULTS

The cost of hospitalization of patients undergoing heart transplantation was $522,997.26 in Brazilian reals ($220,002.58 in US dollars). The Brazilian public health system was responsible for paying the hospital bill of all patients. Female sex, patients up to 40 years of age, and length of stay in the hospital units were variables that were related to the highest values for the hospital service. Clinical complications of the patients during the hospitalization period were also factors that were related to the greater length of stay in the hospitalization units, reflecting higher expenses for the health institution.

CONCLUSIONS

There is a need for health managers to implement strategies that will minimize complications, such as health care-related infections, that can be prevented during hospitalization and to stimulate the allocation of resources in order to improve care and reduce hospital expenses.

Hospitalization costs and their determining factors among patients undergoing kidney transplantation: a cross-sectional descriptive study

BACKGROUND

Cost evaluation is a key tool in monitoring expenditure for budget management. It increases the efficiency of possible changes through identifying potential savings and estimating the resources required to make such changes. However, there is a lack of knowledge of the total cost of hospitalization up to the clinical outcome, regarding patients admitted for kidney transplantation. Likewise, there is a lack of data on the factors that influence the amounts spent by hospital institutions and healthcare systems.

OBJECTIVES

To describe the costs and determining factors relating to hospitalization of patients undergoing kidney transplantation.

DESIGN AND SETTING

Cross-sectional descriptive study with a quantitative approach based on secondary data from 81 patients who were admitted for kidney transplantation at a leading transplantation center in southern Brazil.

METHODS

The direct costs of healthcare for patients who underwent kidney transplantation were the dependent variable, and included personnel, expenses, third-party services, materials and medicines. The factors that interfered in the cost of the procedure were indirect variables. The items that made up these variables were gathered from the records of the internal transplantation committee and from the electronic medical records. The billing sector provided information on the direct costs per patient.

RESULTS

The estimated total cost of patients' hospitalization was R$ 1,257,639.11 (US$ 571,010.44). Out of this amount, R$ 1,237,338.31 (US$ 561,793.20) was paid by the Brazilian National Health System and R$ 20,300.80 (US$ 9,217.24) by the transplantation center's own resources. The highest costs related to the length of hospital stay and clinical complications such as sepsis and pneumonia.

CONCLUSIONS

The costs of hospitalization for kidney transplantation relate to the length of hospital stay and clinical complications.

Dialysis Reimbursement: What Impact Do Different Models Have on Clinical Choices?

Allowing patients to live for decades without the function of a vital organ is a medical miracle, but one that is not without cost both in terms of morbidity and quality of life and in economic terms. Renal replacement therapy (RRT) consumes between 2% and 5% of the overall health care expenditure in countries where dialysis is available without restrictions. While transplantation is the preferred treatment in patients without contraindications, old age and comorbidity limit its indications, and low organ availability may result in long waiting times. As a consequence, 30–70% of the patients depend on dialysis, which remains the main determinant of the cost of RRT. Costs of dialysis are differently defined, and its reimbursement follows different rules. There are three main ways of establishing dialysis reimbursement. The first involves dividing dialysis into a series of elements and reimbursing each one separately (dialysis itself, medications, drugs, transportation, hospitalisation, etc.). The second, known as the capitation system, consists of merging these elements in a per capita reimbursement, while the third, usually called the bundle system, entails identifying a core of procedures intrinsically linked to treatment (e.g., dialysis sessions, tests, intradialyitc drugs). Each one has advantages and drawbacks, and impacts differently on the organization and delivery of care: payment per session may favour fragmentation and make a global appraisal difficult; a correct capitation system needs a careful correction for comorbidity, and may exacerbate competition between public and private settings, the latter aiming at selecting the least complex cases; a bundle system, in which the main elements linked to the dialysis sessions are considered together, may be a good compromise but risks penalising complex patients, and requires a rapid adaptation to treatment changes. Retarding dialysis is a clinical and economical goal, but the incentives for predialysis care are not established and its development may be unfavourable for the provider. A closer cooperation between policymakers, economists and nephrologists is needed to ensure a high quality of dialysis care.

Global costs attributed to chronic kidney disease: a systematic review

SUMMARY The aim of this study is to discuss the global costs attributed to chronic kidney disease (CKD) and its impact on healthcare systems of developing countries, such as Brazil. This is a systematic review based on data from PubMed/Medline, using the key words “costs” and “chronic kidney disease”, in January 2017. The search was also done in other databases, such as Scielo and Google Scholar, aiming to identify regional studies related to this subject, published in journal not indexed in PubMed. Only papers published from 2012 on were included. Studies on CKD costs and treatment modalities were prioritized. The search resulted in 392 articles, from which 291 were excluded because they were related to other aspects of CKD. From the 101 remaining articles, we have excluded the reviews, comments and study protocols. A total of 37 articles were included, all focusing on global costs related to CKD. Despite methods and analysis were diverse, the results of these studies were unanimous in alerting for the impact (financial and social) of CKD on health systems (public and private) and also on family and society. To massively invest in prevention and measures to slow CKD progression into its end-stages and, then, avoid the requirement for dialysis and transplant, can represent a huge, and not yet calculated, economy for patients and health systems all over the world.