Fatores associados à provisão de acesso vascular permanente para hemodiálise: um marcador da qualidade da assistência prestada ao portador de doença renal crônica terminal no Brasil

Abstract

Introduction: Provision of permanent vascular access before hemodialysis is the ideal condition to treat end-stage renal disease (ESRD) patients, because it is associated with lower morbidity and mortality. When this does not happen, these patients start hemodialysiswith temporary catheter. The catheter should be removed as soon as possible. However, in Brazil, most patients have started dialysis with a catheter and have been maintained on hemodialysis in this condition. Objective: To evaluate the provision of permanent vascular access for patients who have hemodialysis as their first treatment modality, as marker of quality of care provided to patients with end stage renal failure (ESRD) in Brazil. Methods: We conducted two studies to evaluate these factors. In the first study, data were analyzed from a cross-sectional study, that obtained through a structured questionnaire conducted with patients with ESRD recruited from selected dialysis services and transplant centers and were representative of the national population. For this investigation, only patients who had hemodialysis as a first dialysis modality were enrolled. Multiple logistic regression (p = 0.05) was applied using as event of interest the first type of vascular access. Thus, based on the algorithm, the probability occurrence was calculated. In the second study, the data used were of a National Database on Renal Replacement Therapy, built from the data available at the High Complexity Procedures Authorization Subsystem of the Outpatient Information System/National Health, from 2000 to 2004. We included only incidents patients, > 18 years, who had hemodialysis as first modality, and had a record for the first arteriovenous fistula (AVF). The event of interest was the time between entry into hemodialysis with temporary central venous catheter until the confection of the first AVF. The CoxRegression was used to assess individual factors associated with the event of interest. For inclusion of variables of the dialysis unit, the Frailty Model was employed. The strength of association for both models of survival was demonstrated by relative risk and its confidence intervals. Results: In the first study, we observed that only 31% of patients startedhemodialysis with a permanent vascular access. In this analysis, five factors remained associated with low probability of an arteriovenous vascular access as the first type of access: time of diagnosis of chronic kidney disease prior to entry into HD = 1 year, shorter lenght of hemodialysis therapy, lack of private health insurance, residence in Northeastern, Midwestern or Southeastern regions and residence in the Northern region combined with a lack of private health insurance. In the second study, approximately 80% of the patients had their first hemodialysis with temporary central venous catheter and about 25% of these remained with this access after three months of treatment. The average time for construction of AVF was 4 ± 7.8 months. The event of interest appeared to be associated to feminin sex, patients with diabetes or hypertension, city and some regions of residence, and number ofhemodialysis rooms in dialysis unit (frailty). Conclusion: It is suggested that greater attention to monitoring dialysis offered, and for improved monitoring of care provided to patients with chronic kidney disease by dialysis centers to enhance quality of care provided to them.