MORBIDITY-MORTALITY EPIDEMIOLOGY AND PUBLIC COSTS OF KIDNEY FAILURE EPIDEMIOLOGIA DA MORBIMORTALIDADE E CUSTOS PÚBLICOS POR INSUFICIÊNCIA RENAL EPIDEMIOLOGÍA DE MORBIMORTALIDAD Y COSTES PÚBLICOS POR INSUFICIENCIA RENAL

Objective: to describe the epidemiology of morbidity-mortality and public costs of kidney failure between 2012-2017. Method: this is a quantitative, ecological and descriptive study, with data from the Hospital Information System. All five Brazilian regions were selected as study population, with the collection of gender, age and race/color variables, values of hospital services, hospitalizations, deaths and mortality rate. Data were analyzed by means of descriptive statistics (absolute and relative frequencies) and presented in the form of tables constructed through Excel software. Results: there were 507.830 hospitalizations due to kidney failure. The highest values were in the Southeast (45.48%), males (56.47%), aged 60 through 64 years (11.10%) and self-reported whites (36.81%). Furthermore, there were 64,977 deaths and mortality rate of 12.8%, with the highest rates in the northern region (13.91%). There was a financial impact exceeding R$ 1.4 billion. Conclusion: kidney failure affects, in greater prevalence, elderly and white men when the outcome is death, resulting in changes in the family dynamics and budget, increased costs to health systems and reduced quality of life. Descritores: Epidemiology; Public Health; Nephrology; Kidney Diseases; Healthcare Costs; Information Systems. RESUMO Objetivo: descrever a epidemiologia da morbimortalidade e custos públicos pela insuficiência renal entre 2012-2017. Método: trata-se de estudo quantitativo, ecológico e descritivo, com dados do Sistema de Informações Hospitalares. Selecionou-se as cinco regiões brasileiras como população de estudo e coletou-se as variáveis sexo, faixa etária, raça/cor, valores dos serviços hospitalares, internações, óbitos e taxa de mortalidade. Analisou-se os dados por meio de estatística descritiva simples (frequências absolutas e relativas) e apresentou-se em forma de tabelas construídas por meio do software Excel. Resultados: registrou-se 507.830 internações por insuficiência renal. Evidenciou-se maior prevalência no Sudeste (45,48%), no sexo masculino (56,47%), entre 60 a 64 anos (11,10%) e autodeclarados brancos (36,81%). Notificou-se, também 64.977 óbitos e mortalidade de 12,8%, com maior taxa na região norte (13,91%). Houve impacto financeiro superior a 1,4 bilhões de reais. Conclusão: conclui-se, que a insuficiência renal aflige em maior prevalência homens idosos e brancos quando o desfecho final é o óbito, implicando em mudanças na dinâmica e orçamento familiar, incremento de custos aos sistemas de saúde e redução da qualidade de vida. Descritores: Epidemiologia; Saúde Pública; Nefrologia; Nefropatias; Custos de Cuidados de Saúde; Sistemas de Informação. RESUMEN Objetivo: describir la epidemiología de la morbimortalidad y costes públicos por insuficiencia renal entre 2012-2017. Método: se trata de un estudio cuantitativo, ecológico y descriptivo, con datos del Sistema de Información Hospitalaria. Fueron seleccionadas las cinco regiones brasileñas como población de estudio y recogidas las variables sexo, edad, raza/color, valores de los servicios hospitalarios, hospitalizaciones, muertes y tasa de mortalidad. Los datos fueron analizados mediante estadística descriptiva (frecuencias absolutas y relativas) y se presentan en forma de tablas construidas mediante software Excel. Resultados: se registraron 507,830 hospitalizaciones por insuficiencia renal. Mayor prevalencia en el sureste (45.48%), el sexo masculino (56.47%), entre 60 y 64 años (11,10%) y auto-declarados blancos (36.81%). También se notificaron 64,977 muertes y tasas de mortalidad del 12,8%, con tasas más altas en la región norte (13.91%). Hubo un impacto superior a los 1.400 millones de reales. Conclusión: Se concluye que la insuficiencia renal aflige, en la mayor prevalencia, hombres ancianos y blanco cuando el resultado final es la muerte, resultando en cambios en la dinámica y el presupuesto familiar, aumento de costes para los sistemas de salud y la reducción de la calidad de vida. Descritores: Epidemiología; Salud Pública; Nefrología; Enfermedades Renales; Costos de la Atención en Salud; Sistemas de Información. Graduates, State University of Southwest Bahia/UESB. Bahia (BA), Brazil. E-mail: edison.vitorio@gmail.com ORCID iD: http://orcid.org/0000-0003-0457-0513; E-mail: robson.matoos@hotmail.com ORCID iD: http://orcid.org/0000-0001-8923-3780; E-mail: ja.mille97@outlook.com ORCID iD: http://orcid.org/0000-0002-5926-3492; E-mail: tayna_freitas11@hotmail.com ORCID iD: http://orcid.org/0000-0002-1595-286X E-mail: aguiar.gbn@gmail.com ORCID iD: http://orcid.org/0000-0002-8738-2990; Special student of the Postgraduate Program in Nursing and Health, State University of Southwest Bahia/UESB. Bahia (BA), Brazil. E-mail: elaynylopes@gmail.com ORCID iD: http://orcid.org/0000-0002-7436-1170; PhD, Postgraduate Porgram in Nursing and Health, State University of Southwest Bahia/UESB. Bahia (BA), Brazil. E-mail: rboery@gmail.com ORCID iD: http://orcid.org/0000-0002-7823-9498; Email: eduardoboery@gmail.com ORCID iD: http://orcid.org/0000-0001-7624-4405 ORIGINAL ARTICLE Souza Júnior EV de, Costa EL, Matos RA et al. Morbidity-mortality epidemiology and public...

Kidney Failure (KF) occurs when renal functions decrease, and can be classified as Acute Kidney Failure (AKF) or evolve to Chronic Kidney Failure (CKF) 1 . AKF consists of a reversible syndrome evidenced by the sudden loss for hours or days of glomerular filtration capacity. 2 CKF is characterized by the last stage of Chronic Kidney Disease (CKD) after a slow, progressive and irreversible loss of renal functions (glomerular ,tubular, and endocrine). 3 In both cases, there is a serum increase of nitrogenous waste such as urea, creatinine, metabolic acids, among others, which change the chemical composition of the blood and interfere with the metabolic and hydroelectrolytic homeostasis. 3,4 The main etiological sources of KF are diabetic nephropathy, Systemic Arterial Hypertension (SAH) and glomerulonephritis. Its development also occurs from pyelonephritis, hereditary lesions, use of nephrotoxic drugs, vascular disorders and exposure to occupational agents as heavy metals, among others. 5 The initial therapy, also called conservative treatment, aims to avoid the progression of complications, using medicines, dietary therapies and control of SAH. When these measures are no longer effective, the treatment changes to Renal Replacement Therapy (RRT), among which stand out Hemodialysis (HD), Peritoneal Dialysis (PD) and Renal Transplantation (RT). 5 The first two therapies are used in the AKF 6 and CKF, 7 while RT is only performed in patients with the chronic form of the disease. 7 The estimates of the KF incidence in Brazil reaches approximately 8% per year, being three times more frequent in patients with heart failure, which potentiates progressive renal lesions since they share the same etiology, SAH, most comprehensive chronic condition in Brazilian statistical data on kidney diseases. 8 Regarding the information presented and, allied to the burden generated for public coffers, KF is considered an important public health problem.
In Brazil, the primary care has been facing financial crises and the high demand ends up overloading the professionals in such a way, who often do not reach efficiency in their actions. Therefore, this study presents itself as relevant to society and the scientific environment, once it provides knowledge and analysis of the Brazilian health situation of KF. Moreover, it allows assessing the effectiveness of public policy and the primary care in the health promotion, protection and recovery context. variables and, in relation to the mortality rate, the northern region stands out with 13.91%. Finally, in this time interval, KF presents an average mortality of 12.8% of deaths.    Table 3 shows that the self-reported white population stands out in the hospitalization service in the entire period, corresponding to 36.80% (n=186.926). The pardo race/color also stands out with 30.62% (n=155.520). Português  In relation to the age variable, the results of this article point to a higher prevalence of KF in the age group 60 through 64 years (11.10%) and the second greatest prevalence in ≥ 80 years (10.68%), as shown in table 2. Another study found results that corroborate these findings, such as the one performed at a university hospital in the city of São Paulo that observed an average age of 65.8 years of hospitalized patients with CKD. 8 When it comes to renal changes, there must be attention to their risk factors, such as aging, presence of heart failure, Diabetes Mellitus (DM) and in particular, SAH, since the probability of developing CKD increases when the individual has associated vulnerabilities. In addition, a study conducted in the capital of São Paulo highlights that, each year of life, the possibility of developing the disease rises  Another study has highlighted the relationship between the risk of death from renal complications and increase of age, such as the survey conducted in Belo Horizonte, which observed the prevalence of 68% of deaths in individuals undergoing dialytic therapy aged over 65 years. 12 The explanation for considering aging a risk factor is the relationship between the aging process of the body and the consequent decrease in the GFR. 13 Considering the color/race variable, a study tends to corroborate the findings of this research (Table 3), indicating a greater prevalence in the white color/race. 8 However, another study done by the national health survey found no significant differences between race/skin color in patients with CKD. 14 Although blacks have a greater prevalence of risk factors for CKD, such as SAH 15 and DM, 16 the white race showed a higher probability of developing the disease. A study conducted in the state of Bahia found similar results, whose mostly black population had a lower incidence of CKF, especially by glomerulonephritis. 17 Even though health professionals collected the color/race information of this study through the users' self-report, and despite a phenotypic variable, it is also a cultural construction of each individual. Similarly, a study of some Brazilian researchers concluded that the perception about race/color shows variable behavior in temporal space, often due to its association with social status. 18 This study showed that, of all KF cases, 56.47% occurred in the male population, according to Table 4, an expected result, since men have physiologically higher probability of developing CKD. 19 A survey conducted in Salvador-BA, which aimed to analyze the medical records of patients with CKD, showed that the number of cases is more prevalent in the male population. 7 Another study done from the DATASUS database in the child population found a prevalence of 60% of males in the cases of hospitalization in children, which is in line with the findings of the present study on the gender variable. 1 Althoug some studies 2,20,21 have evidenced a higher number of women with CKD, men present a higher risk for reduction of GFR, and, consequently, evolution to the chronic form of the disease. 20.21 This relationship results from the greater adherence of women to health services and greater prevalence in this population enrolled in programs of the basic network, such as HiperDia. There is also a greater prevalence of SAH in women aged over 60 years and longer life expectancy at birth (76.5 years), when compared to men. 21 In relation to the financial impact, KF generated a burden exceeding R$ 1.4 billion to Brazilian public coffers, as shown in table 5. The annual expenses with the KF patient in HD involve exams (R$ 539.76), hospitalization (R$ 1,180.00), consultations (R$ 120.00), therapy (R$ 7,829,89), vascular access (R$ 817.57) and dialysis sessions (R$ 25,780,32), totaling R$ 36,267.54 per year. These values refer only to users seronegative for Human Immunodeficiency Virus (HIV) and, for this population, the value increases to R$ 48,538.22 per year due to therapeutic peculiarities. 22 The costs of maintaining dialysis machines still cooperates for lifting the burden generated, since they include costs for recruitment of professionals, material resources and outsourcing of work. Therefore, the monitoring of expenses resulting from renal therapy through HD includes not only the hemodynamic procedure, but also the context of conservation and effectiveness of treatment. Nevertheless, the assistance method performed through HD consists of the main form of intervention directed at patients with renal involvement. 23 The costs of PD treatment are smaller the those of HD. The annual expenses with the first therapy consists of exams (R$ 607.76), hospitalization (R$ 464.86), consultations (R$ 660.00), therapy (R$ 4,642.30), peritoneal access (R$ 549.75) and the treatment itself (R$ 21,498.72), totaling R$ 28,423.39 per year. 22 Furthermore, the PD stands among the RRT procedures due to its simple implementation of the therapeutic resource, as well as the reduced infrastructural demand to reach the targeted assistance purposes, which adds to lower costs in relation to the extracorporeal therapies, such as HD. 24 This technique encompasses the continuous ambulatory peritoneal dialysis (CAPD), the continuous cyclic peritoneal dialysis (CCPD) and intermittent peritoneal dialysis (IPD). 25 adapting to certain existing scenarios.
The discussion on the costs with RT takes into account whether the donated organ came from a Dead Donor (DD) or Living Donor (LD) and the pharmacological group employed in the post-therapy transplant therapy. In this Português However, preliminary values resulting from the RT are still significant and also reflect the burden arising from the implementation of the surgical procedure, since, after it, there are low costs in the use of actions for monitoring and preventing the rejection of organ. 26 The RT represents an option with high cost-benefit ratio while providing improvement in the life quality and expectancy, as a long-term result, when comparing methods of continuous dialysis. 27 More than 80% of the Unified Heatlh System (UHS) finance and control the procedures for the treatment of KF. Furthermore, preventive measures related to risk factors for kidney problems, as well as the active search for these patients in the initial stage, provide reduced costs for the UHS, generating savings for the public coffers. 28 The findings of this study show that kidney failure occurs, in greater prevalence, in elderly and white men when the outcome is death, resulting in changes in the family dynamics and budget, increased costs to health systems and reduced QOL. Moreover, public costs tend to increase due to the aging of the population, consequently, increasing the development of chronic diseases in the Brazilian population.
Thus, it is necessary to strengthen control and prevention actions for KF, especially in the northern region, due to the higher mortality rate recorded. Therefore, Kidney Failure represents an important challenge for public health, and this study provides subsidies to direct preventive strategies at this pathology, especially regarding the control of SAH and DM.
The results of this article originate from the analysis of information of a health information system in the public domain. Therefore, a limitation of the study refers to the possible underreporting. DATASUS data wer chosen because of their easy access, reduced time for data collection and analysis, low cost and because it is one of the main tools for directing the creation and implementation of public health policies.