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Introdução: A doença renal crônica (DRC) consiste em um contexto de diversas perdas para pacientes e cuidadores. Essa realidade corresponde a processos de elaboração de perdas e lutos com impactos sobre a saúde mental de ambos. Objetivo: Avaliar as perspectivas sobre a morte e correlacionar com aspectos de saúde mental e suporte social. Materiais e Métodos: Estudo transversal com 31 participantes, sendo 14 pacientes com doença renal crônica em diálise em um Hospital Universitário no interior de Minas Gerais, Brasil, e 17 familiares. Os instrumentos utilizados foram: questionário sociodemográfico e de saúde, o Questionário de Qualidade de Vida (SF-36); Escala Hospitalar de Ansiedade e Depressão (HADS), Escala de Percepção do Suporte Social (SPSS), Pictograma de Fadiga (PF), Inventário de Sintomas de Estresse de Lipp (ISSL) e Escalas Breves de Perspectivas Sobre Morte (EBPM). Para a análise estatística as variáveis foram descritas como média, desvio padrão, mediana ou frequência conforme sua característica. Foi realizada a correlação de Pearson ou Spearman, considerando p<0,05. O software estatístico SPSS 17.0. Resultados: Os pacientes eram 50% (n= 7) do sexo feminino com idade média de 54,71 (±15,96) anos e os cuidadores eram 70,58% (n= 12) do sexo feminino, com idade média de 50,82 (±14,88) anos. Na avaliação geral (n= 31), houve uma associação negativa do domínio físico do SF-36 com a perspectiva de "morte como coragem" (r= -0,37, p= 0,04), uma associação positiva dos sintomas de ansiedade (r= 0,36, p= 0,04) e de depressão (r= 0,46, p= 0,01) com a perspectiva de morte como "sofrimento e solidão" (EBPM-1). Nos pacientes (n= 14), houve uma associação negativa entre o suporte social prático e a EBPM-1 (r= -0,719, p= ,006). Nos cuidadores, houve uma associação positiva entre as fases do estresse e a EBPM-1 (r= 0,48, p= 0,05). Conclusão: As perspectivas sobre a morte se relacionam com aspectos de saúde mental e suporte social em pacientes com DRC e cuidadores.

Introduction: Chronic kidney disease (CKD) is a context of diverse losses for patients and caregivers. This reality corresponds to processes of processing losses and mourning with impacts on the mental health of both. Objective: To evaluate perspectives on death and correlate with aspects of mental health and social support. Materials and Methods: Cross-sectional study with 31 participants, 14 patients with chronic kidney disease undergoing dialysis at a University Hospital in Minas Gerais, Brazil, and 17 family members. The instruments used were: sociodemographic and health questionnaire, the Quality of Life Questionnaire (SF-36), Hospital Anxiety and Depression Scale (HADS), Perceived Social Support Scale (SPSS), Fatigue Pictogram (PF), Lipp Stress Symptom Inventory (ISSL) and Brief Perspectives on Death Scales (EBPM). For statistical analysis, variables were described as mean, standard deviation, median or frequency according to their characteristics. Pearson or Spearman correlation was performed, considering p<0.05. SPSS 17.0 statistical software. Results: Patients were 50% (n= 7) female with a mean age of 54.71 (±15.96) years and caregivers were 70.58% (n= 12) female, with a mean age of 50. 82 (±14.88) years. In the general assessment (n= 31), there was a negative association between the physical domain of the SF-36 and the perspective of "death as courage" (r= -0.37, p= 0.04), a positive association with symptoms of anxiety (r= 0.36, p= 0.04) and depression (r= 0.46, p= 0.01) with the prospect of death as "suffering and loneliness" (EBPM-1). In patients (n= 14), there was a negative association between practical social support and EBPM-1 (r= -0.719, p= .006). In caregivers there was a positive association between the phases of stress and EBPM-1 (r= 0.48, p= 0.05). Conclusion: Perspectives on death are related to aspects of mental health and social support in CKD patients and caregivers.

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Abstract Introduction: Mild cognitive impairment (MCI) is a prevalent and underdiagnosed condition in chronic kidney disease (CKD), that shares common pathophysiological factors such as chronic inflammation. Objective: To evaluate the association of MCI in CKD stages 1-5 using inflammatory markers and changes by magnetic resonance imaging (MRI). Patients and Methods: Cross-sectional study in adult patients with pre-dialysis CKD. MCI was assessed by the Montreal Cognitive Assessment (MoCA) and the estimated glomerular filtration rate (eGFR) by the Chronic Kidney Disease Epidemiology Collaboration equation. Sociodemographic and clinical data were collected from medical records. The cytokines IL-4, IL-6, IL-17, TNF-α and hs-CRP were determined. Brain MRI was performed in a 1.5 Tesla device, without paramagnetic contrast. A descriptive analysis followed by a comparison of abnormal versus normal MoCA scores among all studied variables. A linear regression analysis was performed using MoCA as a dependent variable, adjusted for confounding factors. Results: Of 111 invited patients, eighty completed the neuropsychological assessment and 56 underwent MRI, and were included in the study. Mean age was 56.3 ± 8.3 years and 51.8% (n = 29) had altered MoCA. When compared to the group with normal MoCA, the group with altered MoCA had higher levels of IL-6 and IL-17. There was no correlation between altered MoCA with eGFR or with MRI abnormalities. Conclusão: MCI assessed by MoCA was prevalent in patients with pre-dialysis CKD, it was associated with inflammation and showed no correlation with MRI changes.

Resumo Introdução: O comprometimento cognitivo leve (CCL) é prevalente e subdiagnosticado na doença renal crônica (DRC), condição com a qual compartilha fatores fisiopatológicos como a inflamação crônica. Objetivo: Avaliar a associação do CCL na DRC estágios 1 a 5, com marcadores inflamatórios e alterações de exames de imagem por ressonância magnética (RM). Pacientes e métodos: Estudo transversal em pacientes adultos, com DRC pré-dialítica. CCL foi avaliado pelo Montreal Cognitive Assessment (MoCA) e a taxa de filtração glomerular estimada (TFGe), pela equação do CKD-EPI. Dados sociodemográficos e clínicos foram coletados nos prontuários médicos. Dosadas citocinas IL-4, IL-6, IL-17, o TNF-α e PCR-us. A RM do encéfalo foi realizada em aparelho de 1,5 Tesla, sem contraste. Realizada análise descritiva seguida por comparação de pontuações do MoCA anormais versus normais entre todas as variáveis estudadas. A regressão linear foi realizada usando MoCA como uma variável dependente, ajustada para fatores de confusão. Resultados: De 111 pacientes convidados, oitenta completaram a avaliação neuropsicológica, 56 realizaram RM, tendo sido incluídos no estudo. A média de idade foi de 56,3 ± 8,3 anos e 51,8% (n = 29) apresentavam MoCA alterado. Quando comparado ao grupo MoCA normal, o grupo MoCA alterado apresentou níveis mais elevados de IL-6 e IL-17. Não houve correlação entre MoCA alterado com TFGe nem com anormalidades na RM. Nos modelos ajustados, a IL-6 foi preditor independente do MoCA alterado Conclusão: O CCL avaliado pelo MoCA foi prevalente em pacientes com DRC pré-dialítica, associou-se com inflamação e não apresentou correlação com alterações da RM.

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Abstract Introduction: 72% of renal replacement therapy (RRT) clinics in Brazil are private. However, regarding payment for dialysis therapy, 80% of the patients are covered by the Unified Health System (SUS) and 20% by private healthcare (PH). Objectives: To evaluate costs for peritoneal dialysis (PD) and hemodialysis (HD) from the perspective of the service provider and compare with fund transfers from SUS and private healthcare. Methods: The absorption costing method was applied in a private clinic. Study horizon: January 2013 - December 2016. Analyzed variables: personnel, medical supplies, tax expenses, permanent assets, and labor benefits. The input-output matrix method was used for analysis. Results: A total of 27,666 HD sessions were performed in 2013, 26,601 in 2014, 27,829 in 2015, and 28,525 in 2016. There were 264 patients on PD in 2013, 348 in 2014, 372 in 2015, and 300 in 2016. The mean monthly cost of the service provider was R$ 981.10 for a HD session for patients with hepatitis B; R$ 238.30 for hepatitis C; R$197.99 for seronegative patients; and R$ 3,260.93 for PD. Comparing to fund transfers from SUS, absorption costing yielded a difference of -269.7% for hepatitis B, +10.2% for hepatitis C, -2.0% for seronegative patients, and -29.8% for PD. For PH fund transfers, absorption costing for hepatitis B yielded a difference of -50.2%, +64.24% for hepatitis C, +56.27% for seronegative patients, and +48.26 for PD. Conclusion: The comparison of costs of dialysis therapy from the perspective of the service provider with fund transfers from SUS indicated that there are cost constraints in HD and PD.

Resumo Introdução: 72% das clínicas de terapia renal substitutiva (TRS) no Brasil são privadas. Entretanto, quanto ao pagamento da terapia dialítica, o Sistema Único de Saúde (SUS) cobre 80% dos pacientes e, a saúde privada (SP), 20%. Objetivos: Avaliar custos de diálise peritoneal (DP) e hemodiálise (HD) na perspectiva do prestador de serviços, comparando com repasses do SUS e saúde suplementar. Métodos: O método de custeio por absorção foi aplicado em clínica privada. Horizonte de estudo: Janeiro 2013 - Dezembro 2016. Variáveis analisadas: pessoal, suprimentos médicos, despesas tributárias, ativos permanentes, benefícios trabalhistas. Utilizou-se para análise o método da matriz de input-output. Resultados: Realizou-se um total de 27.666 sessões de HD em 2013, 26.601 em 2014, 27.829 em 2015, e 28.525 em 2016. Havia 264 pacientes em DP em 2013, 348 em 2014, 372 em 2015, e 300 em 2016. O custo médio mensal do prestador de serviços foi R$ 981,10 por sessão de HD para pacientes com hepatite B; R$ 238,30 para hepatite C; R$ 197,99 para pacientes soronegativos; R$ 3.260,93 para DP. Em comparação com repasses do SUS, o custeio por absorção mostrou uma diferença de -269,7% para hepatite B, +10,2% para hepatite C, -2,0% para pacientes soronegativos, e -29,8% para DP. Para repasses da SP, o custeio por absorção para hepatite B mostrou uma diferença de -50,2%, +64,24% para hepatite C, +56,27% para pacientes soronegativos, e +48,26 para DP. Conclusão: A comparação de custos da terapia dialítica da perspectiva do prestador de serviços com os repasses do SUS indicou que existem restrições de custos em HD e DP.

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INTRODUCTION: Mild cognitive impairment (MCI) is a prevalent and underdiagnosed condition in chronic kidney disease (CKD), that shares common pathophysiological factors such as chronic inflammation. OBJECTIVE: To evaluate the association of MCI in CKD stages 1-5 using inflammatory markers and changes by magnetic resonance imaging (MRI). PATIENTS AND METHODS: Cross-sectional study in adult patients with pre-dialysis CKD. MCI was assessed by the Montreal Cognitive Assessment (MoCA) and the estimated glomerular filtration rate (eGFR) by the Chronic Kidney Disease Epidemiology Collaboration equation. Sociodemographic and clinical data were collected from medical records. The cytokines IL-4, IL-6, IL-17, TNF-α and hs-CRP were determined. Brain MRI was performed in a 1.5 Tesla device, without paramagnetic contrast. A descriptive analysis followed by a comparison of abnormal versus normal MoCA scores among all studied variables. A linear regression analysis was performed using MoCA as a dependent variable, adjusted for confounding factors. RESULTS: Of 111 invited patients, eighty completed the neuropsychological assessment and 56 underwent MRI, and were included in the study. Mean age was 56.3 ± 8.3 years and 51.8% (n = 29) had altered MoCA. When compared to the group with normal MoCA, the group with altered MoCA had higher levels of IL-6 and IL-17. There was no correlation between altered MoCA with eGFR or with MRI abnormalities. CONCLUSÃO: MCI assessed by MoCA was prevalent in patients with pre-dialysis CKD, it was associated with inflammation and showed no correlation with MRI changes.

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INTRODUCTION: 72% of renal replacement therapy (RRT) clinics in Brazil are private. However, regarding payment for dialysis therapy, 80% of the patients are covered by the Unified Health System (SUS) and 20% by private healthcare (PH). OBJECTIVES: To evaluate costs for peritoneal dialysis (PD) and hemodialysis (HD) from the perspective of the service provider and compare with fund transfers from SUS and private healthcare. METHODS: The absorption costing method was applied in a private clinic. Study horizon: January 2013 - December 2016. Analyzed variables: personnel, medical supplies, tax expenses, permanent assets, and labor benefits. The input-output matrix method was used for analysis. RESULTS: A total of 27,666 HD sessions were performed in 2013, 26,601 in 2014, 27,829 in 2015, and 28,525 in 2016. There were 264 patients on PD in 2013, 348 in 2014, 372 in 2015, and 300 in 2016. The mean monthly cost of the service provider was R$ 981.10 for a HD session for patients with hepatitis B; R$ 238.30 for hepatitis C; R$197.99 for seronegative patients; and R$ 3,260.93 for PD. Comparing to fund transfers from SUS, absorption costing yielded a difference of -269.7% for hepatitis B, +10.2% for hepatitis C, -2.0% for seronegative patients, and -29.8% for PD. For PH fund transfers, absorption costing for hepatitis B yielded a difference of -50.2%, +64.24% for hepatitis C, +56.27% for seronegative patients, and +48.26 for PD. CONCLUSION: The comparison of costs of dialysis therapy from the perspective of the service provider with fund transfers from SUS indicated that there are cost constraints in HD and PD.

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Abstract Introduction: Chronic kidney disease (CKD) can progress to end-stage renal disease (ESRD), and clinical studies show that this progression can be slowed. The objective of this study was to estimate the costs to Brazil's public health system (SUS) throughout the course of CKD in the pre-dialysis stage compared to the costs to the SUS of dialysis treatment (DT). Methods: A retrospective cohort study was conducted to analyze clinical and laboratory variables; the outcome analyzed was need for DT. To assess cost, a microcosting survey was conducted according to the Methodological Guidelines for Economic Evaluations in Healthcare and the National Program for Cost Management, both recommended by the Brazilian Ministry of Health for economic studies. Results: A total of 5,689 patients were followed between 2011 and 2014, and 537 met the inclusion criteria. Average costs increased substantially as the disease progressed. The average cost incurred in stage G1 in Brazilian reals was R$ 7,110.78, (US$1,832.06) and in stage G5, it was R$ 26,814.08 (US$6,908.53), accumulated over the four years. Conclusion: A pre-dialysis care program may reduce by R$ 33,023.12 ± 1,676.80 (US$ 8,508.26 ± 432.02) the average cost for each year of DT avoided, which is sufficient to cover the program's operation, minimizing cost. These results signal to public health policy makers the real possibility of achieving significant cost reduction in the medium term for CKD care (4 years), to a program that disbursed R$ 24 billion (US$ 6.8 billion) for DT in Brazil between 2009 and 2018.

Resumo Introdução: Doença renal crônica (DRC) pode progredir para doença renal estágio terminal (DRET). Estudos clínicos mostram que esta progressão pode ser retardada. Objetivo: estimar custos para o sistema público de saúde (SUS) do Brasil durante o curso da DRC no estágio pré-diálise, comparado com os custos para o SUS do tratamento dialítico (TD). Métodos: Conduziu-se estudo de coorte retrospectivo para analisar variáveis clínicas e laboratoriais; o desfecho analisado foi a necessidade de TD. Para avaliar os custos, realizou-se pesquisa de microcustos de acordo com as Diretrizes Metodológicas para Avaliações Econômicas em Saúde e o Programa Nacional de Gestão de Custos, ambos recomendados pelo Ministério da Saúde Brasileiro para estudos econômicos. Resultados: Acompanhou-se um total de 5.689 pacientes entre 2011-2014; 537 preencheram os critérios de inclusão. Os custos médios aumentaram substancialmente à medida que a doença progrediu. O custo médio incorrido no estágio G1 em reais foi R$ 7.110,78 (US$ 1.832,06) e no estágio G5 foi R$ 26.814,08 (US$ 6.908,53), acumulado durante os quatro anos. Conclusão: Um programa de atendimento pré-dialítico pode reduzir em R$ 33.023,12 ± 1.676,80 (US$ 8.508,26 ± 432,02) o custo médio para cada ano de TD evitado. Isso é suficiente para cobrir a operação do programa, minimizando custos. Estes resultados sinalizam aos formuladores de políticas de saúde pública a possibilidade real de alcançar redução significativa de custos em médio prazo para o cuidado da DRC (4 anos), para um programa que desembolsou R$ 24 bilhões (US$ 6,8 bilhões) para TD no Brasil entre 2009-2018.