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According to World Kidney Day, an international non-profit organization, about 10% of the world's population suffers from chronic kidney disease, which can be fatal if the patient does not receive proper treatment. Campaigns around the world surrounding World Kidney Day, celebrated on March 10, have grown as a way of warning about this disease that is still quite invisible and unknown. But the death rate has increased, according to World Health Organization, increasing concern about kidney health.
In Brazil, this scenario is also critical. O 2022 Brazilian Nephrology Census collected alarming data indicating a significant increase in the number of people who need dialysis treatment in Brazil. In 2022, the country had a total of 153,831 patients on dialysis, marking a growth of 57.6% over the last decade and a notable increase of 182.1% in the period from 2003 to 2022.
This increase in dialysis patients is a reflection of the increasing presence of kidney diseases in the population, such as Chronic Kidney Disease (CKD). In 2020, Marcelo Mazza, president of the Brazilian Society of Nephrology (SBN), pointed out that CKD can be considered a epidemic, affecting one in ten adults. This is a condition that gradually impacts kidney function over time, decreasing the filtration capacity of waste and excess fluids in the blood. Several conditions, such as diabetes mellitus, high blood pressure, and autoimmune diseases, can cause CKD, with a prevalence of the first two conditions.
This worrisome scenario is compounded by the population's lifestyle. Diabetes and hypertension are increasingly common and are strongly influenced by dietary and exercise issues. The increase in obesity and the aging of the population also contribute to the incidence of chronic diseases. If these conditions are not treated properly, CKD can develop as a complication, prompting demand for dialysis treatment.
Still, another important aspect to be considered is the improvement of diagnostic techniques, allowing the early identification of kidney diseases. This also influences an increase in the number of patients requiring dialysis treatment. In addition, awareness campaigns about the importance of early diagnosis of kidney problems have contributed to the search for dialysis services, which, in turn, increases the number of patients receiving a diagnosis.
It should be noted that CKD can be classified into stages ranging from one to five. In the first stage, kidney function is still considered normal, but kidney lesions can be identified on imaging tests. In stage two, symptoms may not yet be evident, but kidney function begins to decline. In the third phase, the function has already undergone significant impairment and the symptoms may worsen. At stage four, the symptoms are already more pronounced and the need for intervention becomes urgent. Already in the most advanced phase, the fifth phase, known as the terminal phase of chronic renal failure, there is a demand for a complex of treatments called Renal Replacement Therapy (TRS). Within this set of treatments, there is dialysis, which has several modalities: hemodialysis, peritoneal dialysis, and hemodiafiltration.
CKD treatments and cost-benefit
Hemodialysis is the most prevalent form of treatment, representing more than 90% of therapies both in the Unified Health System (SUS) and in private clinics. In this procedure, the patient's blood is filtered out of the body by a machine called a dialyzer. The blood passes through a filter that removes waste and excess fluids, such as urea and creatinine, providing a rapid improvement in symptoms, before being reintroduced into the patient's body. In general, hemodialysis requires regular sessions and it is worth noting that home treatment is not allowed in Brazil, requiring the patient to travel.
Meanwhile, peritoneal dialysis (DP) represents a more flexible alternative for treating chronic kidney failure, allowing the patient to perform the procedure at home. In this method, a dialysis fluid is introduced into the patient's abdomen through a permanent catheter. The peritoneal membrane in the abdomen acts as a natural filter, allowing the removal of waste and excess fluids. In Brazil, the main types of peritoneal dialysis include continuous outpatient PD, which involves four daily changes and can be performed at home. Automated PD, on the other hand, is often performed during the night, also in a home environment, with six to seven changes. Still, automated PD tends to have a smaller impact on a patient's blood pressure, which may be beneficial, especially for those with cardiovascular problems.
Hemodiafiltration, on the other hand, is a technique that combines elements of hemodialysis and conventional filtration, seeking to increase efficiency in removing toxins from the blood. In this method, the removal of substances and excess fluids occur through a combination of diffusion and convection. Hemodiafiltration is performed in specialized centers and its prescription may vary in frequency according to the individual needs of the patient. In recent years, the procedure has experienced a significant increase in the number of patients using it. Despite its therapeutic advantages, this modality requires more specialized equipment, which may be more expensive and has limited availability in some regions.
Regarding the cost-benefit of these dialysis modalities, there is no absolute consensus. Most studies indicate that hemodialysis has a lower cost, but it should be noted that these analyses, in general, do not reflect on all aspects of efficacy, quality and clinical results. This type of approach follows the current logic of cost to the payer, and not of a value-based health discussion. It should also be noted that the frequency and duration of Renal Replacement Therapy treatment may vary depending on the medical prescription, the clinical condition of each patient, and other individual factors.
Brazil's challenges and NefroClínicas
Given the urgent scenario taking place in the country, there has been a significant increase in the number of dialysis centers in recent years, but the Brazilian Nephrology Census indicates that the number of patients requiring dialysis is still higher than the number of active clinics. Another latent health issue in Brazil - which is reflected in the context of kidney diseases - concerns access and the uneven distribution of care in Brazilian regions. There is an enormous challenge for patients who live in areas further away from large centers to gain access to treatments.
In this context, there is NefroClinics in 2019 with the objective of following the entire journey of chronic renal patients. The network serves more than 60 health operators and currently has units distributed throughout Belo Horizonte, Rio de Janeiro, Volta Redonda, Brasília, São Luís and Curitiba, providing about 90,000 treatments and more than 25,000 preventive consultations annually. In an exclusive interview with Green Rock, the founders of NefroClínicas stress that Brazilian health is going through a challenging moment, aggravated by the pandemic.
“In the post-COVID period, with an increase in hospitalizations and surgical procedures, health plans are experiencing a period of high utilization and accident rates. Currently, chronic kidney disease affects 10% of the Brazilian population. More than 150,000 patients undergo dialysis procedures every year in Brazil, according to the 2022 Census of the Brazilian Society of Nephrology. The current care model has proven to be inefficient in dealing with the challenges imposed by the condition, generating increasingly high costs and low perception of value by patients”.
NefroClínicas also points out that CKD can affect men and women, “which may vary by region, age, lifestyle, and genetics”. However, it also highlights diabetes and hypertension as risk factors, so that habits related to smoking, physical activities, and diet can also influence this condition.” People who use over-the-counter medications and have cases of kidney disease in the family should also be aware. A simple creatinine blood test can detect a kidney problem.”
NefroClínicas also points out that in Brazil most people receive a late diagnosis, which complicates the entire process. As a result, patients start Renal Replacement Therapy as a matter of urgency in hospital units and suffer from the natural complications of a neglected disease, which increases treatment costs. “After this complex moment, within the hospital universe, patients find it difficult to access all levels of outpatient care for adequate continuity of their treatment,” she continues.
In this context, NefroClínicas, which only provides supplementary health care, focuses on the wide offer of outpatient care, coordinated care and care in the main hospitals, focusing on efficient hospital management.
Trending discussions: dehospitalization and value-based health
The founders also bring up the debate about the dehospitalization as an important point in the context of kidney diseases, stressing that it reduces expenses and waste of resources, favoring the entire system. “Home care can be extremely useful. Many patients end up staying in the hospital just because they still need to undergo hemodialysis sessions,” they say.
In this sense, NefroClínicas is committed to this aspect. The founders explain that the network has a dehospitalization and home care program that aims to provide patients with safe care, provide an effective return to their routines and maximize their recovery.
In addition, the issue of compensation models is also discussed. Currently, the great current health model is fee-for-service, so a change to value-based health is not trivial. But at NefroClínicas, the founders seek to take risks to offer incentives and reduce resource waste: “in addition to the monthly monitoring of indicators that we do, really focusing on outcomes is what allows us to seek balance in the system”. In this sense, NefroClínicas says that the line of care and management of Renal Replacement Therapy focused on outcomes goes against what exists today.
“At NefroClínicas, we have been practicing value-based compensation models for over four years, in which compensation is provided for comprehensive patient monitoring and is linked to clinical outcome indicators, ensuring that everything necessary will be done by the patient. We have a 'case' where more than 1.6 million beneficiaries have at their disposal treatments that are effectively value-based when affected by kidney disease,” they add.
The importance of prevention
Another important point highlighted by NefroClínicas is the centrality of prevention in the context of chronic diseases. “The NefroClínicas model is one of coordinated care, its premise is to reduce dialysis and, when necessary, to choose the method that promotes the best outcomes”. With this proposal, according to them, the network already covers 1.6 million lives and generates a significant reduction in claims.
NefroClínicas also highlights the relevance of actions and campaigns aimed at raising public awareness, together with medical societies and civil society entities. “We believe that education is an important and robust arm. Patients followed by us have significantly higher rates of deceleration of CKD than unmanaged patients. Nefroacademy is one of the training and continuing education arms of the NefroClínicas group and provides quality updates for doctors. To date, more than 20 events have been held, impacting an audience of more than 1,500 health professionals,” they add.
Next steps from NefroClínicas
Regarding the future of the network, NefroClínicas is currently expanding partnerships with health operators and already has some value-based models that have provided efficiency to the sector and reduced accidents. In addition, the founders also say that a strong investment has been made in training the team.
“New units and new hospitals are on our radar in various regions of the country for the coming years. In addition, we are incorporating artificial intelligence tools for patient navigation and management, guaranteeing our public continuous and timely care”, they conclude.
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