End-Stage Renal Failure and National Resources: The Brazilian Experience

Abstract

Brazil is the fifth largest and the fifth most populous nation in the world. Its economy rivals Mexico as the strongest in Latin America and ranks among the 15 largest economies in the world. Despite these achievements, a substantial fraction of the Brazilian population still lives in poverty, and many still have limited access to medical assistance. There are currently about 380 patients on hemodialysis per million populations (pmp), approximately one third of the U.S. prevalence, suggesting that a large fraction of end-stage renal disease (ESRD) patients are not diagnosed and treated properly. In Brazil, access to renal replacement therapy (RRT), including renal transplantation, is universal, and the corresponding costs, including those of medications (immunosuppressors and treatment of ESRD complications), are covered by the Brazilian government. However, given the continuous growth of the ESRD population and of the costs incurred by RRT, the efficacy and reach of this system may be severely limited in years to come. In the current struggle against the ESRD epidemics, the Brazilian medical community and health authorities face a triple challenge: to limit the incidence of renal disease, slow or detain the progression of established chronic nephropathies, and ensure that access to quality RRT remains granted to all those who, despite all efforts, reach ESRD.

Keywords:

• end-stage renal disease
• renal replacement therapy
• health care cost

DEMOGRAPHIC DATA

Brazil is the fifth largest nation in the world, occupying nearly half of South America's area, and holds the fifth largest population of the planet. Most of the more than 180 million Brazilians live in urban areas, mainly by the eastern and southeastern coasts, where most of the industrial activities and services are concentrated. At about 600 billion U.S. dollars, Brazil's GDP is the 14^th largest among over 200 countries. When the Purchase Parity Power (PPP) is considered, Brazil occupies the 9^th position, at nearly 1.5 trillion U.S. dollars. However, Brazil's income per capita is only around 8,100 U.S. dollars, 85^th in the world. Moreover, there is a severe inequality in the distribution of wealth and resources, as shown by such indicators as the Gini index (0.59, the 8^th worst in the world) and the human development index, HDI (0.775, 72^nd position).

Almost 60% of the Brazilian population is constituted by Caucasians, descendants of Portuguese colonizers or European immigrants. African descendants (∼35%) represent the second most important ethnic group. The remaining 5% include descendants of Asian and Semitic immigrants, as well as sparse communities of Native Brazilians. The age composition of the Brazilian population has changed steadily in the past decades. While individuals aged 65 or more constituted only 5% of the population in 1980, this percentage is now estimated at about 9%, and is expected to reach about 13% (more than 26 million people) by the year 2020. Accordingly, life expectancy at birth has shifted from less than 60 to more than 70 years, whereas life expectancy at 40 years of age now exceeds 75 years of age.[1]

EPIDEMIOLOGY OF CHRONIC NEPHROPATHY IN BRAZIL

Data on the prevalence of chronic renal disease in Brazil are scarce. In a survey carried out in Bambuí, a small inland city of Southeastern Brazil,[2] 0.5% of the population aged 18–59 years and 5.1% of those aged 60 years and older were found to have serum creatinine levels in excess of 1.3 mg/dL (men) and 1.1 mg/dL (women), whereas the prevalence of hypertension in the same age brackets was 20% and 60%, respectively. By extrapolating these figures to the overall Brazilian population in 2005, the total number of people suffering from chronic kidney disease (CKD) could be coarsely estimated at 1.7 million. The CKD population can also be estimated by assuming that there may exist 25 CKD patients for each one on chronic hemodialysis.[2] Because there are currently about 70,000 patients (∼380 pmp) on chronic dialysis in Brazil, the CKD population in the country could be estimated at 1.75 million, which is in good agreement with the estimate based on the Bambuí study (see Figure 1).

Figure 1 Schematic view of the interactions between the diverse subpopulations of patients with CKD in Brazil.

According to data obtained from the Brazilian Ministry of Health, glomerular disease was the main cause of ESRD in the 1980s. Although primary glomerulopathies (especially focal segmental glomerulosclerosis) still persists as a major cause of chronic nephropathy in Brazil, accounting for nearly 20% of all registered cases of ESRD between 1997 and 2000, more recent data indicate that this profile has changed drastically: diabetic nephropathy and hypertensive nephrosclerosis are now responsible for most cases of ESRD.[3–5] As in other parts of the world, this undoubtedly reflects the aging of the population, which is associated with an increase in the prevalence of hypertension, metabolic syndrome, obesity, and Type II diabetes.[5]

MANAGEMENT OF CKD AND RENAL REPLACEMENT THERAPY (RRT) IN BRAZIL

Conservative treatment of CKD involves essentially so-called medium complexity procedures (visits to outpatient clinics, periodic blood tests, pharmacological and nonpharmacological blood pressure control, etc). However, primary medical attention is still limited in Brazil, which results in late diagnosis and referral of CKD. As a consequence, CKD patients are often first seen at predialysis stages and followed at dialysis centers (“highly complex” medicine), rather than at ordinary outpatient clinics.

An estimated 18,000 new ESRD patients per year (see Figure 1), corresponding to ∼100 patients per million population (pmp), are incorporated into the population of patients on chronic dialysis (mostly hemodialysis), currently estimated at 70,000 (∼380 pmp).[5] Corresponding figures in developed countries range from 1,000 to 1,400 pmp,[6] suggesting that ESRD is largely underdiagnosed (and/or undertreated) in Brazil, possibly because a substantial part of the population has limited access to medical attention.

The population of transplanted patients, currently estimated between 20,000 and 25,000 (110–135 pmp), represents less than a quarter of the total RRT population, in contrast with the figures for European and North-American countries, which are nearly twice as high.[6] The current waiting list is close to 30,000, up from 4,000 in 1992. About 3,200 renal transplants/year (∼17 ppm) are currently performed in Brazil (as opposed to 46 pmp in the United States and 41 pmp in Sweden). This represents less than one-third of what would be necessary to merely stabilize the waiting list. About 40% of the transplanted kidneys are currently obtained from living donors, as opposed to 10% in Europe and 30% in the United States.

In contrast with the glaring deficiencies in the conservative management of CKD, and despite the country's economic limitations, RRT has been provided with relative success in Brazil. There are now nearly 18 nephrologists/pmp (corresponding to about 1 nephrologist per 55,000 inhabitants). The Brazilian Society of Nephrology (SBN) has more than 2000 registered members, and RRT centers exist in virtually the entire Brazilian territory, comprising 561 dialysis and 143 renal transplant units. The quality of the RRT services provided in Brazil is comparable to that found in developed countries: mortality is currently less than 15%/year for chronic dialysis[5] and 4% for transplanted patients,[7] whereas the prevalence of hepatitis B and C infection is low and has decreased steadily in recent years.[5]

On the basis of the current figures, it can be easily calculated that the population of patients on chronic dialysis is increasing at about 8,000 per year, far from becoming stable. Stabilization may take even longer and the number of patients on RRT increase even higher as adequate medical attention is extended to an increasing fraction of the population and the dialysis-related mortality decreases as a result of improving medical care (see Figure 1). Thus, measures destined to limit the progression of CKD to ESRD, including early detection and rigorous treatment of diabetes and hypertension, are urgently needed.

FUNDING RRT

Access to RRT has been granted by law to all those in need for it. RRT in Brazil is funded mostly by the Brazilian government, whereas private and corporate coverage amounts to less than 5% of the total. The Ministry of Health pays approximately $46 U.S. per hemodialysis session, including medical fees, while CAPD costs ∼$500 U.S. per patient per month. The total direct expenses with RRT amount to ∼$650 million U.S., of which ∼$500 million U.S. are assigned to dialysis and $150 million U.S. to transplant patients. Additionally, the Ministry of Health covers the cost of the main drugs used in the maintenance of these patients, as well as that implied by hospitalization, and also for the transplantation procedure (∼$10,000 U.S., including medical honoraria). However, the financing of these expenses has become problematic in recent years as the government has been reluctant to increase the funds assigned to RRT, even in the face of an ever-increasing ESRD population.

CONCLUSION

The ESRD population is growing steadily in Brazil, imposing an increasing burden on the health system. The profile of ESRD tends to follow that observed in more developed countries. The real prevalence of CKD may be underestimated, due to underdiagnosis and limited access of a large fraction of the population to medical care. More than 95% of expenses associated with RRT are financed by the government, although the viability of this system is threatened by the coexistence of growing costs and inelastic resources. As in most countries, urgent measures for the early diagnosis and referral of CKD, as well as for arresting its progression, are badly needed.

Notes

7. State of Sao Paulo Transplant System. Report on Survival. 2003.