Iniquities in the access to renal transplant for patients with end-stage chronic renal disease in Brazil Iniquidades no acesso ao transplante renal para pacientes com doença renal crônica terminal no Brasil

The objective of this present study is to analyze individual and contextual factors associated with access to renal transplant in Brazil. An observational, prospective and non-concurrent study was carried out, based on data from the National Database on renal replacement therapies in Brazil. Patients undergoing dialysis between 01/Jan/2000 and 31/Dec/2000 were included and monitored up to the point of transplant, death or until the end of the study period. Variables that were analyzed included: individual variables (age, sex, region of residence, primary renal disease, hospitalizations); and context variables concerning both the dialysis unit (level of complexity, juridical nature, hemodialysis machines and location) and the city (geographic region, location and HDI). Proportional hazard models were adjusted with hierarchical entry to identify factors associated with the risk of transplant. The results point to differentials in access according to socio-demographic, clinical, geographic and social factors, indicating that the organ allocation system has not eliminated avoidable disparities for those who compete for an organ in the nationwide waiting list. Kidney Transplantation; Health Inequalities; Accessibility to Health Services; Chronic Kidney Failure Introduction Chronic kidney disease is a worldwide public health problem that reduces life expectancy and typically progresses to end-stage chronic renal disease and a need for renal replacement therapy 1. The renal replacement therapies available are dialysis (hemodialysis and peritoneal dialysis) and renal transplant. Renal transplantation is preferred over dialysis for the treatment of many patients with end-stage chronic renal disease because it improves both survival and quality of life, reducing long-term costs of care 2,3,4. In absolute numbers of kidney transplantations, Brazil ranks second among all countries, after the United States, and ranks ninth when corrected per million inhabitants 5. The Brazilian Unified National Health System (SUS) 6 pays for more than 95% of transplants performed in the country 5, and provides the necessary post-transplant medication and follow-up, representing a growing demand upon public resources 7. Previous studies have showed disparities in the access to kidney transplant. These discrepancies are mainly attributed to individual sociocultural variables (race/ethnicity, sex, age, educational level, social support networks and personal beliefs); socioeconomic factors (income, private health insurance), and clinical conditions (comorbid, time on dialysis, histocompatibility, blood type, access to primary health care and late referral to a nephrologist) 8,9,10,11,12,13,14,15. ARTIGO ARTICLE INIQUITIES IN ACCESS TO RENAL TRANSPLANT IN BRAZIL S285 Cad. Saúde Pública, Rio de Janeiro, 27 Sup 2:S284-S297, 2011 Contextual characteristics related to the dialysis units and transplant centers, in addition to the patient’s area of residence and neighborhood poverty have also been associated with the probability of access to transplant 8,16,17,18. In Brazil, despite the existence of a National Policy of Care to Patients with Renal Disease (Decree no. 1,168 of 15/Jul/2004) that assures coverage and equity in the performance of renal transplant 19, auditing reports have shown unequal access to renal transplant, mainly for low-income populations, and those without private health insurance or who live in remote areas that are far from transplant centers 20. However, there are no nationwide studies 7 that evaluate access to kidney transplantation. One possibility is the use of information obtained by administrative data systems related to the SUS registry of payments for medical procedures for patients under renal replacement therapy. The databases have been used to answer relevant questions about epidemiological profiles in the area of chronic renal disease 21,22. The social relevance of transplants, as well as the absence of nationwide studies that analyse the individual and contextual determinants that generate iniquities in the access to renal transplant, justify this investigation. The present study describes and analyzes, using various database sources, the socio-demographic, clinical and contextual factors associated with access to renal transplant in Brazil.