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1 Origial Article Artigo Origial Prevalece of diabetes mellitus i chroic kidey patiets o hemodialysis i Porto Alegre, Brazil Prevalêcia de diabetes mellitus em pacietes reais crôicos sob hemodiálise em Porto Alegre, Brasil Authors Jayme Eduardo Burmeister 1 Camila Borges Mosma 2 Reata Bau 2 Guido Araha Rosito 3 1 Departmet of Medical Cliic ad Disciplie of Nephrology i the Medical School of Uiversidade Luteraa do Brasil ULBRA Caoas RS Brazil. 2 ULBRA Caoas RS Brazil 3 Departmet of Medical Cliic i the Medical School of ULBRA Caoas RS Brazil; Uiversidade Federal de Ciêcias da Saúde of Porto Alegre UFCSPA Porto Alegre RS Brazil Submitted o: 8/1/211 Approved o: 11/16/211 Abstract Itroductio: The most commo cause of chroic real failure (CRF) amog patiets who are startig o dialysis i developed coutries is diabetes mellitus (DM), with growig rates approachig. I Brazil, the available data idicate a lower prevalece, aroud 27, eve though it is also icreasig. Objectives: To estimate the prevalece of DM i the adult populatio of patiets o hemodialysis for CRF i Porto Alegre, Brazil. Methods: Cross-sectioal, descriptive, quatitative ad aalytical survey study o the prevalece of DM amog the 1,288 patiets o hemodialysis (HD) i all the 15 cliics i the city from Jue to July, 29. Results: 488 diabetic patiets were idetified, a prevalece of 37.9, ragig from i the differet cliics of the city. Coclusios: The prevalece of DM amog chroic HD patiets i Porto Alegre is higher tha what was previously published as a cause of CRF i the coutry, which idicates the possibility that this etiology of CRF may have bee uderestimated. Keywords: Prevalece. Diabetes mellitus. Real dialysis. Kidey failure, chroic. Resumo Itrodução: A causa mais frequete de isuficiêcia real crôica (IRC) os pacietes iiciado tratameto dialítico os países desevolvidos é o diabetes mellitus (DM), com ídices crescetes e que hoje se aproximam de. No Brasil, os dados dispoíveis idicam que essa prevalêcia é iferior, em toro de 27, embora veha aumetado. Objetivos: Estimar a prevalêcia de DM a população adulta de pacietes em tratameto hemodialítico por IRC em Porto Alegre, Brasil. Métodos: Estudo trasversal descritivo, quatitativo e aalítico, com iquérito sobre a prevalêcia de DM etre os pacietes em tratameto por hemodiálise (HD) crôica as 15 clíicas do muicípio os meses de juho e julho de 29. Resultados: 488 pacietes diabéticos foram idetificados, uma prevalêcia de 37,9, variado de as diferetes clíicas da cidade. Coclusões: A prevalêcia de DM etre pacietes em HD crôica em Porto Alegre é muito superior ao que tem sido atribuído como causa de IRC o país, o que idica a possibilidade de que essa etiologia de IRC possa estar sedo subestimada. Palavras-chave: Prevalêcia. Diabetes mellitus. Diálise real. Falêcia real crôica. Correspodece to: Prof. Jayme Eduardo Burmeister Aveida Coroel Lucas de Oliveira 127, apto. 31, Bela Vista Porto Alegre RS Brazil CEP jb.efro@gmail.com This study was udertake at ULBRA Caoas RS Brazil. The authors report o coflict of iterest. Itroductio Diabetes mellitus (DM) is the mai cause of chroic real failure (CRF) i patiets startig o hemodialysis (HD) i developed coutries, which represets almost of the ew cases. 1,2 Europea ad North-America records idetified that these umbers have progressively grow. 2,3 This pheomeo seems to be maily due to the icreased prevalece of DM i the geeral populatio, 4 ad has bee a reaso for cocer i the medical commuity, especially amog ephrologists, for its possible future cosequeces. I Brazil, there are some publicatios that aalyzed the prevalece of DM as the cause of CRF i patiets o HD, but most were published may years ago, usually with data that were restricted to idividual or regioal services

2 Prevalece of diabetes mellitus i hemodialysis i Porto Alegre Records of the Brazilia Society of Nephrology (SBN) have bee the exceptios; i 1999, a epidemiologic survey showed prevalece of 17 i the coutry (beig 19 i the South Regio). 12 More recetly, a publicatio aalyzig the epidemiologic profile of chroic kidey patiets that were o real replacemet therapy (RRT) i Brazil, from 2 to 24, foud DM as the cause of kidey disease i 18 of the subjects. 13 Brazilia cesus of HD promoted by SBN i 28 ad 29 estimated this prevalece to be 25.7 ad 27, respectively. 14,15 These data suggest the progressive icrease also i Brazil. Evaluatios cocerig the growig prevalece of DM i subjects o HD are relevat for public health plaig, sice this group of patiets eeds complex care, which geerates more costs, besides presetig higher morbidity ad mortality rates i compariso to o-diabetic patiets This study aimed to estimate the prevalece of DM i patiets with CRF udergoig HD i the city of Porto Alegre, Brazil, ad their distributio i the differet care ceters i the city. Methods This cross-sectioal study was performed from Jue to July, 29, i all of the 15 dialysis cliics i Porto Alegre, icludig data separated by service ad the total umber of patiets o treatmet for CRF with itermittet outpatiet dialysis. The study was approved by the Research Ethics Committee at Uiversidade Luteraa do Brasil ULBRA. Data were obtaied directly from the doctors ad urses i charge of each of the dialysis uits i the city. From Jue 2 to July 15, 29, the first author of this text cotacted oe of the techicias i charge (doctor or urse) of each dialysis cliics i Porto Alegre by telephoe, explaiig the iitial objective of the study to estimate the prevalece of DM amog patiets o HD due to CRF. He also explaied that this iformatio would be used for a sample calculatio, based o aother study with idividual data o the prevalece of cardiovascular risk factor i diabetics udergoig HD (ogoig study called CORDIAL). He asked for the total umber of subjects aged 18 years or more who were o RRT with HD, as well as the umber of patiets diagosed with DM i this group, regardless of the cause defied for CRF. Statistical aalysis was performed with the Chisquare test with Yates correctio usig the statistical software GraphPad istat (GraphPad Software Ic., Sa Diego CA, EUA). The level of statistical sigificace was established as p <.5. Results I the period of the study from Jue to July, 29 1,288 chroic kidey patiets were reported to be o HD treatmet i the 15 differet cliics i Porto Alegre. I total, 488 diabetic patiets were idetified prevalece of 37.9, ragig from 21 to 75 i the differet ceters. Table 1 shows the distributio of patiets grouped accordig to locatios of treatmet (hospital ceters of dialysis or autoomous cliics), ad accordig to the istitutio that is resposible for fiacig the treatmet Natioal Health System (SUS) or health isurace compaies. Table 2 shows the distributio of the populatio i the study i the 15 dialysis ceters i the city durig this period. Graph 1 compares the ceters that care exclusively for patiets who have health isurace (68 diabetics Table 1 Distributio of patiets ad prevalece of diabetes mellitus i the differet types of hemodialysis services i the city Types of Service Total DM Prevalece of DM Uiversity hospitals SUS ,6 Public hospitals SUS , Private hospitals SUS ,6 Private hospitals health isurace plas ,8 Autoomous cliics SUS ,5 Autoomous cliics health isurace plas , Geeral Total ,9 SUS: Sistema Úico de Saúde (Uified Health System); DM: diabetes mellitus. 118 J Bras Nefrol 212;34(2):

3 Prevalece of diabetes mellitus i hemodialysis i Porto Alegre amog 136 subjects prevalece of ) with the other ceters, i which patiets are mostly from SUS (42 diabetics amog 1,152 patiets prevalece of 36.5), with a sigificat differece (p =.28). Graph 2 compares dialysis ceters i hospitals (275 diabetic patiets amog 86 subjects prevalece of 34.1) with autoomous cliics (213 diabetics amog 482 subjects prevalece of 44.2) p =.4. This differece is eve more sigificat whe comparig oly those who are assisted by SUS: 212 diabetics amog 695 patiets i hospitals (prevalece of 3.5) versus 28 diabetics amog 457 patiets i cliics (prevalece of 45.5) p =.1 (Graph 3). Graph 4 compares uiversity hospitals that mostly care for SUS patiets (88 diabetics amog 331 patiets prevalece of 26.6) with other services that care for SUS patiets (332 diabetics amog 821 patiets prevalece of.4) p =.1. Graph 1. Prevalece of diabetes mellitus i hemodialysis ceters with patiets who have health isurace ad the oes from SUS (p =.28). 6,,, 3, 2,,,, SUS: Brazilia Health System. 36,5 Health isurace plas SUS Graph 2. Prevalece of diabetes mellitus i itrahospital services ad autoomous cliics (p =.4). Discussio The fidig of almost of diabetics amog chroic kidey patiets o HD i the city is greatly relevat. Cosiderig the previous available data, there seems to be a sigificat icrease, comparable Table 2 Serviços de Hemodiálise Total of patiets o hemodialysis ad prevalece of diabetes mellitus i the 15 dialysis ceters of the city Total DM Prevalece DM A B C D E F G H I J K L M N O Geeral total 1, DM: diabetes mellitus Hospital ceters Autoomous cliics Graph 3. Prevalece of diabetes mellitus i patiets of Brazilia Health System (SUS), itra-hospital services ad autoomous cliics (p =.1) Hospital ceters Autoomous cliics J Bras Nefrol 212;34(2):

4 Prevalece of diabetes mellitus i hemodialysis i Porto Alegre Graph 4. Prevalece of diabetes mellitus i patiets of Brazilia Health System (SUS), uiversity hospitals ad other hospitals/cliics (p =.1) ,6 SUS: Brazilia Health System.,4 Uiversity ceters SUS Others SUS to data from urba populatios i developed coutries. This icreased prevalece rate i relatio to prior studies is owed to differet factors amog others, the possibility of a regioal pheomeo, sice obesity ad DM are more commo i the South Regio of Brazil; 19,2 the reductio i mortality rates amog diabetic patiets o HD, as has bee observed i other coutries; 3 the presece of elderly patiets with DM2 (which is at least partially a reflex of the higher life expectacy of diabetics i the geeral populatio); 21 ad the icrease i obesity i the geeral populatio. 22 All the prior records available o the prevalece of DM with HD i Brazil show lower prevalece of DM i compariso to ours. Besides local or regioal studies, it is worth to metio those that covered the whole coutry. Cherchiglia et al. 13 foud a 15 prevalece of DM as the cause of kidey disease amog all patiets that were o RRT with HD i Brazil from 2 to 24. This study was based o admiistrative records from databases of high-complexity procedures (Autorizações de Procedimetos de Alta Complexidade APAC), of the Outpatiet Iformatio System (SIA), of SUS; these data are iserted at the admissio of each patiet for dialysis at SUS. However, this idex ca be uderestimated, sice the records of this system poit to a idetermiate cause as the reaso for chroic kidey disease (CKD) i 43 of the cases startig o HD, which is pretty high ad probably represets the iitial o-idetificatio of the causes for CKD, so it may or may ot demostrate cliical reality. Besides, the records of SIA/SUS do ot iclude patiets o chroic HD who are subsidized by health isurace plas; this group correspods to 13.3 of the total i the coutry, accordig to estimates of SBN. 15 I 29, the Brazilia Dialysis Cesus, by SBN, foud the prevalece of 27 for DM o HD i the coutry. 15 Cosiderig that the results i this study (37.9 i Porto Alegre) is also from 29, the differece is relevat, so the existece of local ad/or regioal factors are possible to justify it. O oe had, sice the SBN cesus does ot preset data per regio, it is impossible to perform ay comparative aalysis. O the other had, the sigificat lower prevalece of DM i the dialysis ceters of Porto Alegre that care for patiets from SUS (compared to those who oly care for patiets with health isurace plas) (Graph 1), as well as the same fidig whe comparig hospital ceters ad autoomous cliics (Graphs 2 ad 3), ad also uiversity hospitals with the others dialysis ceters of SUS (Graph 4), it is importat to coduct more specific aalysis to search for motives. The study had some limitatios, such as: data were obtaied by telephoe from the professioals i charge of each service, istead of a separate idetificatio of the situatio of each patiet i loco; also, there was o attempt to idetify cases i which the cause of CKD could have bee other tha the diabetic ephropathy, eve though the most relevat epidemiological iformatio is the presece of DM itself. Fially, the prevalece of diabetes mellitus i the populatio of chroic kidey adult patiets o HD i the city of Porto Alegre is close to, which is higher tha the prevalece observed i previous studies i Brazil. Such prevalece is much higher tha that regarded as the cause of CRF amog patiets o HD i the coutry. New ad careful epidemiological studies that approach the growig cotributio of DM for CRF are ecessary. Refereces 1. Locatelli F, Pozzoi P, Vecchio LD. Real replacemet therapy i patiets with diabetes ad ed-stage real disease. J Am Soc Nephrol 24;15 Suppl:S Uited States Real Data System (USRDS). Excerpts from 29. Aual data report: Atlas of ed-stage real disease i the Uited States. Am J Kidey Dis 2;55 Suppl:S1. 3. Va Dijk PC, Jager KJ, Stegel B, et al. Real replacemet therapy for diabetic ed-stage real disease: data from registries i Europe (1991-2). Kidey It 25;67: Bommer J. Prevalece ad socio-ecoomic aspects of chroic kidey disease. Nephrol Dial Trasplat 22;17 Suppl: J Bras Nefrol 212;34(2):

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