The importance of vascular access for hemodialysis in Brazil

Access for hemodialysis has been, is and will continue to be one of the major challenges for surgeons and physicians treating terminal chronic renal failure.

There are currently approximately 100 thousand patients receiving dialysis treatment in Brazil and this figure grows by around 10% annually, with about 50 thousand new accesses created per year¹.

Incidence in Brazil is at 149 people per million members of the population (pmp) and prevalence is around 450 pmp. These figures put Brazil in the top 20 countries in the world in terms of incidence and the top 40 countries in terms of prevalence. In South America, both Chile and Uruguay have higher rates. An idea of the potential for growth of dialysis treatment in Brazil can be gauged from the fact that some countries, such as Japan and Taiwan, have already reached prevalence rates of more than 2,000 pmp (Figure 1)^{2 , 3}.

Figure 1
Incidence and Prevalence rates per million population members in different countries.

Hypertension and diabetes are the two primary causes of terminal chronic renal failure (TCRF), accounting for 35.1% and 28.4%, respectively; while 31.5% of patients are over 65 years old¹.

In view of these figures, it can be concluded that vascular access will continue to be one of the most common arterial vascular surgeries conducted in Brazil, with a high incidence of elderly and diabetic patients, which greatly affects the results⁴.

Since 2005, four multidisciplinary congresses on vascular access for hemodialysis have been held in São Paulo, Brazil.

Table 1 summarizes the number of participants per Society and the overall number of attendees.

Table 1
Number of participants per society at the four Brazilian Multidisciplinary Congresses on Vascular Access for Hemodialysis.

	2005	2007	2010	2013
SBACV	251 (43%)	135 (28,5%)	176 (35%)	186 (40,3%)
SBN	204 (35%)	143 (30,2%)	147 (29,3%)	102 (22%)
SOBEN	129 (22%)	196 (41,3%)	179 (35,7%)	174 (37,7%)
Total	584	474	502	462

• SBACV = Sociedade Brasileira de Angiologia e de Cirurgia Vascular; SBN = Sociedade Brasileira de Nefrologia; SOBEN = Sociedade Brasileira de Enfermagem em Nefrologia.

It will be noted that these numbers are not very impressive for a themed congress dedicated to a subject that is of such interest to our specialty. Considering that the SBACV has three thousand members, just 12% of the Society attended. Furthermore, peers who are opinion formers, such as professors and heads of hospital departments, only attended this congress on vascular access in the role of invited speakers.

The same situation can be observed at the major congresses run by the specialties involved. In other words, when access is covered, there is normally only a single presentation on the subject, generally relegated to the end of the day.

Indeed, vascular access does not arouse the interest of the more experienced surgeons and opinion formers and, as a result, fails to interest younger surgeons and those still in training. It is clear that vascular access cannot call on the economic power of the healthcare products industry since the best option is an autologous AVF, meaning that manufactured products are of secondary importance.

We believe that this lack of interest needs to be addressed and that vascular access must be viewed with fresh eyes, taking account of the new situation.

The first priority is to meet the demand for a pool of well-trained vascular surgeons, which is indispensable in view of the increasing number of patients on dialysis treatment, the increasing complexity of these procedures caused by the aging of the population starting hemodialysis, the increasing number of diabetes patients and the need to treat complications such as aneurysms, pseudoaneurysms and steal syndrome, among others.

All of these procedures are, in my view at least, the preserve of vascular surgeons and we cannot abdicate this responsibility.

One of the major problems in providing vascular access is the low value of the fees paid by the Brazilian national health service (SUS) and also by health insurance companies, which would have a negative impact on any health professional's interest. The board of the SBACV, in its professional advocacy role, and also the other medical societies involved, must dedicate themselves with to this problem with rigor.

During the IV Brazilian Congress on Vascular Access, we proposed that the specialties should unite to lobby for a review of the table of fees, adding new procedures and raising the figures paid. In July of this year (2013) we made a presentation the Ministry of Health together with the President of the Brazilian Nephrology Society proposing a new list of procedures and an updated fee structure for vascular access.

We hope to see an updated version of the table shortly.

There is another factor that is very important with respect to ensuring vascular access: it is necessary for surgeons to practice daily in order to master a delicate and sophisticated surgical technique employing delicate materials and arterial sutures of small vessels and demanding training in the use of fine threads with the aid of magnification.

In conclusion, given the growing prevalence of this disease, which requires access for hemodialysis, it is imperative that greater space is dedicated at the SBACV National Congresses to discussion of this important subject and that efforts be made to increase the number of vascular surgeons attending themed congresses.

REFERENCES

• ¹
  Sesso RCC, Lopes AA, Thomé FS, Lugon JC, Watanabe Y, Santos DR. Diálise Crônica no Brasil - Relatório do Censo Brasileiro de Diálise, 2011. J Bras Nefrol. 2012;34(3):272-7. http://dx.doi.org/10.5935/0101-2800.20120009
  » http://dx.doi.org/10.5935/0101-2800.20120009
• ²
  Levey AS, Coresh J. Chronic Kidney Disease, Lancet. 2012; 379:165-80. http://dx.doi.org/10.1016/S0140-6736(11)60178-5
  » http://dx.doi.org/10.1016/S0140-6736(11)60178-5
• ³
  Kepler J. International Comparisons. United States Renal Data System. 2010 Annual Data Report: atlas of kidney disease and end stage renal disease in the United States, v. 2 Atlas of ESRD. [accessed 2011 June 12]. http:QQwww.usrds.org/2010pdf/v2_12.pdf.
  » QQwww.usrds.org/2010pdf/v2_12.pdf
• ⁴
  Das Neves MA Jr, Petnys A, Melo RC, Rabboni E. Acesso vascular para hemodiálise: o que há de novo? J Vasc Bras. 2013;12(3):221-5.

Publication Dates

• Publication in this collection
  Oct-Dec 2013

History

• Received
  23 Oct 2013
• Accepted
  19 Nov 2013