Registry of access to chronic dialysis initiation at the Public Health System in Brazil

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Abstract
Introduction We aim to analyze the requests for the initiation of kidney replacement therapy (KRT) in the public health system of the state of São Paulo, Brazil. Methods Initial KRT requests sent to the Regulation Center of the State Department of Health between 01/01/2023 and 12/31/2024 were evaluated. KRT initiation was considered “planned” if it occurred outside the hospital environment or the patient started hemodialysis (HD) with an arteriovenous fistula (AVF). Results A total of 8451 individuals from 17 healthcare macroregions were included [median interquartile range (IQR)] age: 62 (51–71) years; male sex: 60%; etiology of CKD: 57% hypertension and 21% diabetes). Conservative predialysis treatment of CKD was implemented for 26% of patients in the state, ranging from 4 to 44% in the macroregions. The percentage of patients initiating HD with AVF was 10% (variation in macroregions: 4–25%), and people who initiated KRT in hospital were 70% (37–94%). The initial modality was HD in 95% of the patients (range: 73–100%) (peritoneal dialysis in 5% [(0–27%)], and the median waiting time for a KRT slot vacancy was 12 (IQR: 6–29) days (1 (1–4) to 31 (14–75) in macroregions). Multiple regression analysis revealed that conservative treatment of CKD was independently associated with planned initiation of KRT (odds ratio [OR] [95% confidence interval (CI) = 4.99 (4.48–5.54); p < 0.001]. Conclusion The results demonstrate the need to adopt actions to implement pre-dialysis care for people with CKD and to mitigate regional inequalities in access to chronic dialysis in this population.

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