Análise do pré-transplante renal no Brasil – modelagem da linha de cuidados e abordagem de custos top-down sob a perspectiva do Sistema Único de Saúde

Abstract

Introduction: Chronic Kidney Disease (CKD) is characterized by the progressive and irreversible loss of renal function. Its definition was systematized in 2002 by the Kidney Disease Outcomes Quality Initiative (KDOQI), which established diagnostic and classification criteria. In 2012, these parameters were revised and expanded by Kidney Disease Improving Global Outcomes (KDIGO), promoting international standardization of management guidelines. The International Society of Nephrology reports that CKD affects over 850 million people worldwide. By 2040, CKD is projected to become the fifth leading cause of years of life lost globally. Although kidney transplantation is the most effective treatment for CKD, it depends on a compatible donor and a multidisciplinary evaluation encompassing clinical, bureaucratic, and economic criteria. In Brazil, where the Unified Health System (Sistema Único de Saúde -SUS) is the primary funder of transplant, a detailed understanding of pre-transplants costs is essential for resource optimization. However, this topic remains underexplored and lacks rigorous cost-analysis methodologies. Objective: This study aimed to conduct an economic analysis of the pre-transpant costs for kidney recipients, living donors (LD), and deceased donors (DD) across each stage of the care pathway, using a topdown micro-costing approach from the SUS perspective. Additionally, it sought to model the care pathway for kidney transplantation with both LD and DD based on production records from DATASUS. Method: A retrospective cohort study was conducted over a ten-year period (2012–2022), including kidney donors living/deceased and recipients. Data were sourced from the National Transplant System (SNT) and DATASUS. AS the data are publicly accessible, ethics committee approval was not required, in accordance with Brazilian Law 12,527 (November 18,2011). Methodological steps followed the Consolidated Health Economic Evaluation Reporting Standards (CHEERS). The care pathway was modeled by integrating procedures listed in SUS/SIGTAP Table group 05 – organ, tissue and cell transplants – including all items related to the evaluation of kidney recipients and donors. Costs were calculated in Brazilian reais (BRL). A statistical model was developed to simulate pre-transplant demand, accounting for variability and irregularities in SUS data. Results: The annual cost of evaluating LDs was BRL 7,656,267.77; for DDs< BRL 93,384,340.54; and for recipients, BRL 75,665,688.25. DD evaluation represented the largest share of total costs. Among procedures, immunological tests were the most intensive resource. Procedure 0501050019 (reactivity assessment of the recipient against panel in hypersensitized organ recipients) was the costliest for recipients (BRL 47,684,772.90), while procedure 0501040064 (crossmatch testing for deceased donor recipients) incurred the highest cost in DD evaluation. Conclusion: This study provides a novel and detailed mapping of pre-transplant kidney costs within SUS, applying CHEERS criteria. DD evaluation accounted for the largest portion of costs, with immunological testing representing the most significant investment among procedures.