|Citation: Lugon JR, Strogoff-de-Matos JP. Comparing costs of renal replacement therapy in a Brazilian city: a case for improvement of our health policies. J Bras Nefrol 39(02):106. doi:10.5935/0101-2800.20170027|
|Received: March 09 2017; Accepted: March 21 2017|
Chronic kidney disease (CKD) is an important health problem affecting close to 13% of the global adult population.1 The treatment of advanced CKD, referred as end-stage renal disease (ESRD), is costly and may represent a substantial economic burden for developed as well as developing nations. Non-rarely, countries may spend more than 8% of their health budget with the treatment of less than 2% of population.2
Renal replacement therapy (RRT) modalities in ESRD include hemodialysis (HD), peritoneal dialysis (PD) and kidney transplantation. The vast majority of ESRD patients are worldwide managed by hemodialysis, but the modality of RRT that offers the best survival and improved quality of life is kidney transplantation.3,4 Data from developed as well as developing countries indicate that kidney transplantation is the most cost-effective modality of RRT.5-7
In the present issue of the journal, Gouveia et al.8 present an interesting analysis of the economic impact of the RRT program in Curitiba, Paraná, Brazil, employing chart review and cost analysis by procedure for a 6-month period. Costs related to medications and hospital admissions were estimated and also taken into account. In spite of the pitfalls inherent to the strategy adopted to estimate the costs of the different modalities of RRT, the authors concluded that from the second year on the annual costs of kidney transplantation were substantially lower than the ones of other RRT modalities. Comparisons were also made between PD and hemodialysis provided by either the public health system or private health care organizations. Based on their findings which are in line with previous studies,5-7 the authors suggest that the health care policies regarding treatment of ESRD should be directed to the most cost-effective modality, kidney transplantation.
Will kidney transplantation be the main modality to treat ESRD in a near future? Currently the answer to this question is almost certainly "No", mainly because of the unfavorable proportion of donation and demand for organs. Even in countries with the best performances, the deceased donation rate is lower than 50 pmp, with most of the countries in the world sitting far below these outstanding numbers.9 If we take into account that, in developed countries, the annual incidence rates of treated ESRD reach figures ranging from 350 to 450 patients pmp,10 it can be concluded that dialysis will continue to be the mainstay therapy to treat ESRD for a long time.
The annual incidence rate of treated ESRD in developing countries are in general lower perhaps due to restricted access to treatment but, in general, also far exceeds the annual donation rate. In Brazil, for instance, the estimated annual incidence rate of ESRD in 2014 was 180 pmp,11 whereas the annual rate of deceased donation was 14 pmp.12
The finding that dialysis will continue as the main mode of RRT for years should not be seen as an obstacle to stimulating kidney transplantation. In line with the conclusion of the study by Gouveia et al.,8 it is our view that the public health system as well as the private health care organizations should undertake efforts to encourage kidney transplantation as the primary modality for ESRD treatment by promoting the expansion of the donation pool and providing an adequate funding.