| spelling |
Augusto Afonso Guerra Júniorhttp://lattes.cnpq.br/4998210231373901Paulo Dorneles PiconEverton Nunes da SilvaDaniel Resende FaleirosCharles Simão FilhoMicheline Rosa Silveirahttp://lattes.cnpq.br/8395018794734460Rosângela Maria Gomes2021-03-17T22:56:20Z2021-03-17T22:56:20Z2020-08-17http://hdl.handle.net/1843/35218https://orcid.org/0000-0001-8299-4835Introdução: No Brasil, o Sistema Único de Saúde (SUS) é universal e responsável por 95% de todos os transplantes renais. Os esquemas imunossupressores consistem em corticosteróide, inibidor da calcineurina (CNI) (ciclosporina ou tacrolimus), agente antiproliferativo (azatioprina ou micofenolato) e sirolimus ou everolimus. O impacto econômico causado pela distribuição desses medicamentos no SUS é crescente. Objetivos: O objetivo desta tese foi avaliar a efetividade e custo- efetividade entre regimes terapêuticos utilizados na manutenção do transplante renal. Métodos: Coorte histórica aberta de 2000 a 2015, envolvendo 44.795 pacientes transplantados renais pelo SUS, construída por meio de pareamento determinístico-probabilístico de bases de dados do Sistema Nacional de Informações em Saúde. Artigo-1 realizou-se análise de sobrevida do enxerto renal dos pacientes que realizaram transplante renal no SUS. A probabilidade acumulada de sobrevida foi estimada por Kaplan-Meier. Potenciais fatores associados à perda do enxerto foram avaliados por análises uni e multivariada pelo modelo de Cox. Artigo-2 realizou-se análise de efetividade dos regimes de tratamento contento CNI após transplante renal. Os pacientes foram pareados (1: 1). A efetividade foi estabelecida pela sobrevida do enxerto avaliada pelo método de Kaplan-Meier e modelo de Cox. Artigo-3 foi realizado avaliação econômica de custo-efetividade na perspectiva do SUS, conduzida a partir de dados da coorte histórica com pacientes submetidos a transplante renal e que usaram CNI. Resultados: A taxa de sobrevida do enxerto renal foi de 91,2%, 77,0%, 57,5% e 42,1% para um, cinco, dez e 15 anos respectivamente. A maioria dos pacientes era do sexo masculino, que realizaram transplante com órgão de doadores falecidos e idade mediana de 42 anos. Maior risco de perda do enxerto foi associado ao órgão proveniente de doador falecido (HR 1.64; IC 95% 1.55 -1.73), anos adicionais de idade (1.013; 1.011 -1.015), cor da pele preta (1.54; 1.39 – 1.71), maior tempo de diálise anterior ao transplante (1.20; 1.14 -1.26), diagnóstico primário de diabetes mellitus (1.21; 1.09 -1.34), hipertensão arterial (1.19, 1.14 -1.25) e regimes de medicamentos contendo micofenolato. A avaliação de efetividade dos regimes terapêuticos incluiu 2.318 pacientes e demonstrou maior risco de perda do enxerto em pacientes em uso do regime tacrolimus mais micofenolato (2.17; 1.02- 2.41) em comparação aos pacientes tratados com ciclosporina mais azatioprina. A avaliação de custo-efetividade apontou que o regime ciclosporina mais azatioprina foi custo- efetivo em comparação com os demais regimes avaliados. Conclusões: A avaliação econômica demonstrou que o regime ciclosporina mais azatioprina foi custo- efetivo comparado com os demais regimes avaliados. Esses achados podem ser úteis para orientar os formuladores de políticas e prescritores na prática clínicaIntroduction: In Brazil, Unified Health System is universal and responsible for ninety-five percent of all kidney transplants. The immunosuppressive regimens required after transplantation consist of a corticosteroid, a calcineurin inhibitor (cyclosporine or tacrolimus), an antiproliferative agent (azathioprine or mycophenolate mofetil), and sirolimus or everolimus. Objectives: The objective of this thesis was to compared the cost-effectiveness of therapeutic regimens used in the maintenance of kidney transplantation in SUS. Methods: Open historical cohort from 2000 to 2015, involving 44,795 kidney transplant patients by SUS in Brazil, constructed through deterministic-probabilistic matching of databases of the SUS. Article-1 analysis of the survival of renal graft of patients was performed. Patients who underwent kidney transplantation in SUS. The cumulative probability of survival was estimated by Kaplan-Meier. Potential factors associated with graft loss were assessed by univariate and multivariate analyzes using the Cox model. Article-2 the effectiveness analysis of treatment regimes containing CNI after kidney transplantation. Effectiveness was established by patient survival assessed by the KaplanMeier method. The patients were matched (1: 1). Article-3 has performed a cost-effectiveness evaluation in SUS perspective, carried out from data from the historical cohort from 2000 to 2015, with 2,318 patients who underwent kidney transplantation and who used CNI. Results: The renal graft survival rate was 91.2%, 77.0%, 57.5% and 42.1% for one, five, ten and 15 years respectively. Most of the patients were men, who underwent organ transplant from deceased donors and median age of 42 years. Higher risk of graft loss was associated with deceased donor organ (HR = 1.63; 95% CI 1.55 - 1.73), additional years of age (1.013; 1.011 -1.015), patients of black skin color (1.54; = 1,390 - 1.710), longer dialysis time prior to transplantation (1.203; 1.112 -1.268), primary diagnosis of diabetes mellitus (1.206; 1.089 -1.336), arterial hypertension (1.118, 1.114 -1.259) and mycophenolate regimens. The effectiveness assessment after paired analysis included 2,318 patients and demonstrated a higher risk of graft loss in patients using tacrolimus plus mycophenolate (2.17; 1.02-2.241) compared to those treated with cyclosporine plus azathioprine. The cost-effectiveness assessment showed that cyclosporine plus azathioprine demonstrated to be more cost effective compared to other regimens. Conclusions: The economic evaluation showed that the cyclosporine plus azathioprine regimen was cost effective than the other regimens evaluated. These findings can be useful to guide policy makers and prescribers in clinical practice.CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível SuperiorporUniversidade Federal de Minas GeraisPrograma de Pós-Graduação em Medicamentos e Assistencia FarmaceuticaUFMGBrasilFARMACIA - FACULDADE DE FARMACIATransplante renalRegimes imunossupressoresAnálise de sobrevidaSistema Único de SaúdeDados do mundo realAnálise de custo-efetividadeCusto-efetividade dos regimes imunossupressores utilizados na manutenção do transplante renal: coorte de dezesseis anos no Sistema Único de SaúdeCost-effectiveness of immunosuppressive regimens used in maintaining kidney transplantation: a sixteen-year cohort in the Brazilian Health Systeminfo:eu-repo/semantics/publishedVersioninfo:eu-repo/semantics/doctoralThesisinfo:eu-repo/semantics/openAccessreponame:Repositório Institucional da UFMGinstname:Universidade Federal de Minas Gerais (UFMG)instacron:UFMGORIGINALTese_RosângelaMariaGomes_UFMG_2020.pdfTese_RosângelaMariaGomes_UFMG_2020.pdfapplication/pdf4480038https://repositorio.ufmg.br/bitstream/1843/35218/1/Tese_Ros%c3%a2ngelaMariaGomes_UFMG_2020.pdff3a0c431be643af0066b6f6d00761ad5MD51LICENSElicense.txtlicense.txttext/plain; charset=utf-82119https://repositorio.ufmg.br/bitstream/1843/35218/2/license.txt34badce4be7e31e3adb4575ae96af679MD521843/352182021-03-17 19:56:20.8oai:repositorio.ufmg.br:1843/35218TElDRU7Dh0EgREUgRElTVFJJQlVJw4fDg08gTsODTy1FWENMVVNJVkEgRE8gUkVQT1NJVMOTUklPIElOU1RJVFVDSU9OQUwgREEgVUZNRwoKQ29tIGEgYXByZXNlbnRhw6fDo28gZGVzdGEgbGljZW7Dp2EsIHZvY8OqIChvIGF1dG9yIChlcykgb3UgbyB0aXR1bGFyIGRvcyBkaXJlaXRvcyBkZSBhdXRvcikgY29uY2VkZSBhbyBSZXBvc2l0w7NyaW8gSW5zdGl0dWNpb25hbCBkYSBVRk1HIChSSS1VRk1HKSBvIGRpcmVpdG8gbsOjbyBleGNsdXNpdm8gZSBpcnJldm9nw6F2ZWwgZGUgcmVwcm9kdXppciBlL291IGRpc3RyaWJ1aXIgYSBzdWEgcHVibGljYcOnw6NvIChpbmNsdWluZG8gbyByZXN1bW8pIHBvciB0b2RvIG8gbXVuZG8gbm8gZm9ybWF0byBpbXByZXNzbyBlIGVsZXRyw7RuaWNvIGUgZW0gcXVhbHF1ZXIgbWVpbywgaW5jbHVpbmRvIG9zIGZvcm1hdG9zIMOhdWRpbyBvdSB2w61kZW8uCgpWb2PDqiBkZWNsYXJhIHF1ZSBjb25oZWNlIGEgcG9sw610aWNhIGRlIGNvcHlyaWdodCBkYSBlZGl0b3JhIGRvIHNldSBkb2N1bWVudG8gZSBxdWUgY29uaGVjZSBlIGFjZWl0YSBhcyBEaXJldHJpemVzIGRvIFJJLVVGTUcuCgpWb2PDqiBjb25jb3JkYSBxdWUgbyBSZXBvc2l0w7NyaW8gSW5zdGl0dWNpb25hbCBkYSBVRk1HIHBvZGUsIHNlbSBhbHRlcmFyIG8gY29udGXDumRvLCB0cmFuc3BvciBhIHN1YSBwdWJsaWNhw6fDo28gcGFyYSBxdWFscXVlciBtZWlvIG91IGZvcm1hdG8gcGFyYSBmaW5zIGRlIHByZXNlcnZhw6fDo28uCgpWb2PDqiB0YW1iw6ltIGNvbmNvcmRhIHF1ZSBvIFJlcG9zaXTDs3JpbyBJbnN0aXR1Y2lvbmFsIGRhIFVGTUcgcG9kZSBtYW50ZXIgbWFpcyBkZSB1bWEgY8OzcGlhIGRlIHN1YSBwdWJsaWNhw6fDo28gcGFyYSBmaW5zIGRlIHNlZ3VyYW7Dp2EsIGJhY2stdXAgZSBwcmVzZXJ2YcOnw6NvLgoKVm9jw6ogZGVjbGFyYSBxdWUgYSBzdWEgcHVibGljYcOnw6NvIMOpIG9yaWdpbmFsIGUgcXVlIHZvY8OqIHRlbSBvIHBvZGVyIGRlIGNvbmNlZGVyIG9zIGRpcmVpdG9zIGNvbnRpZG9zIG5lc3RhIGxpY2Vuw6dhLiBWb2PDqiB0YW1iw6ltIGRlY2xhcmEgcXVlIG8gZGVww7NzaXRvIGRlIHN1YSBwdWJsaWNhw6fDo28gbsOjbywgcXVlIHNlamEgZGUgc2V1IGNvbmhlY2ltZW50bywgaW5mcmluZ2UgZGlyZWl0b3MgYXV0b3JhaXMgZGUgbmluZ3XDqW0uCgpDYXNvIGEgc3VhIHB1YmxpY2HDp8OjbyBjb250ZW5oYSBtYXRlcmlhbCBxdWUgdm9jw6ogbsOjbyBwb3NzdWkgYSB0aXR1bGFyaWRhZGUgZG9zIGRpcmVpdG9zIGF1dG9yYWlzLCB2b2PDqiBkZWNsYXJhIHF1ZSBvYnRldmUgYSBwZXJtaXNzw6NvIGlycmVzdHJpdGEgZG8gZGV0ZW50b3IgZG9zIGRpcmVpdG9zIGF1dG9yYWlzIHBhcmEgY29uY2VkZXIgYW8gUmVwb3NpdMOzcmlvIEluc3RpdHVjaW9uYWwgZGEgVUZNRyBvcyBkaXJlaXRvcyBhcHJlc2VudGFkb3MgbmVzdGEgbGljZW7Dp2EsIGUgcXVlIGVzc2UgbWF0ZXJpYWwgZGUgcHJvcHJpZWRhZGUgZGUgdGVyY2Vpcm9zIGVzdMOhIGNsYXJhbWVudGUgaWRlbnRpZmljYWRvIGUgcmVjb25oZWNpZG8gbm8gdGV4dG8gb3Ugbm8gY29udGXDumRvIGRhIHB1YmxpY2HDp8OjbyBvcmEgZGVwb3NpdGFkYS4KCkNBU08gQSBQVUJMSUNBw4fDg08gT1JBIERFUE9TSVRBREEgVEVOSEEgU0lETyBSRVNVTFRBRE8gREUgVU0gUEFUUk9Dw41OSU8gT1UgQVBPSU8gREUgVU1BIEFHw4pOQ0lBIERFIEZPTUVOVE8gT1UgT1VUUk8gT1JHQU5JU01PLCBWT0PDiiBERUNMQVJBIFFVRSBSRVNQRUlUT1UgVE9ET1MgRSBRVUFJU1FVRVIgRElSRUlUT1MgREUgUkVWSVPDg08gQ09NTyBUQU1Cw4lNIEFTIERFTUFJUyBPQlJJR0HDh8OVRVMgRVhJR0lEQVMgUE9SIENPTlRSQVRPIE9VIEFDT1JETy4KCk8gUmVwb3NpdMOzcmlvIEluc3RpdHVjaW9uYWwgZGEgVUZNRyBzZSBjb21wcm9tZXRlIGEgaWRlbnRpZmljYXIgY2xhcmFtZW50ZSBvIHNldSBub21lKHMpIG91IG8ocykgbm9tZXMocykgZG8ocykgZGV0ZW50b3IoZXMpIGRvcyBkaXJlaXRvcyBhdXRvcmFpcyBkYSBwdWJsaWNhw6fDo28sIGUgbsOjbyBmYXLDoSBxdWFscXVlciBhbHRlcmHDp8OjbywgYWzDqW0gZGFxdWVsYXMgY29uY2VkaWRhcyBwb3IgZXN0YSBsaWNlbsOnYS4KCg==Repositório InstitucionalPUBhttps://repositorio.ufmg.br/oaiopendoar:2021-03-17T22:56:20Repositório Institucional da UFMG - Universidade Federal de Minas Gerais (UFMG)false
|