To analyze the costs of a specialized service in Traditional Complementary and Integrative Medicines (TCIM) in Northeast Brazil to provide data on the cost linked to the implementation and maintenance of services of this nature and to identify the average cost per user for the Unified Health System. This is a partial, descriptive, quantitative economic assessment, which used secondary data, later grouped in Microsoft Excel spreadsheets. The method used to analyze such costs was absorption costing, from which the service was divided into three costing centers: productive, administrative and auxiliary. After analyzing the data, the total cost of the service in 2014 was estimated at R$ 1,270,015.70, with a proportion of 79.69% of direct costs. The average cost per user in this period was R$ 36.79, considering the total of 34,521 users in individual and collective practices. The service has a cost per user compatible with a specialized service; however, TCIM offers a comprehensive and holistic approach, which can have a positive impact on quality of life. The social, institutional and academic recognition of MTCI reinforces the idea that the biomedical model coexists with other forms of care, in a cultural context characterized by pluralistic therapy3.The increasing insertion of Traditional, Complementary and Integrative Medicines (TCIM)4. In Brazil, they are called in the Unified Health System (SUS) of Integrative and Complementary Practices in Health (ICPH)1, coming from different rationalities in health. The supply of ICPH in SUS has recently expanded, totaling 29 practices from complex systems or therapeutic resources, being: homeopathy, phytotherapy/medicinal plants, acupuncture/traditional Chinese medicine, anthroposophical medicine, social thermalism/crenotherapy, art therapy, ayurveda, biodance, circular dance, meditation, music therapy, naturopathy, osteopathy, chiropractic, reflexotherapy, reiki, shantala, integrative community therapy, yoga, aromatherapy, apitherapy, bioenergetics, family constellation, chromotherapy, geotherapy, hypnotherapy, laying on of hands, ozone therapy and flower therapy5.TCIM focuses on the integral approach of the human being, bringing together the physical, psychological, cultural and social systemsSuch expansion of supply deserves more in-depth analyses and studies in the field of economic evaluation that support decision-making in SUS on this topic.1. This occurs due to several factors, such as: absence of trained professionals, lack or insufficiency of financial resources to implement and maintain the services and low knowledge about the costs and effectiveness of these services6.This reality provides subsidies for the emergence of new services within SUS that respond to the wishes of users, health professionals and managers, as well as the scientific community. However, TCIM are weakly institutionalized and distributed heterogeneously in the country7. Given its limits, this assessment can subsidize investment in the quality of care as it allows reallocating and optimizing resources. Regarding TCIM services, this parallel with cost accounting is poorly documented, which generates administrative distortions and difficulties in estimating the value of the service and/or TCMI procedures for SUS. Considering the lack of scientific production that focuses on TCIM costs, our study aimed to estimate the costs of a specialized TCIM service in Northeast Brazil.Public administration has shown a trend towards more professional management, with cost assessment. This view of managerial efficiency has been implemented in public health institutions8 from the perspective of public management, using absorption costing from a public unit specialized in TCIM, offering differentiated individual and collective practices and the production of therapeutic supplies, located in João Pessoa (Paraíba). The absorption costing method aims to identify costs as direct, since it groups them into centers that depend on them to carry out their core activities. Only items that cannot be exclusively allocated to the respective cost centers will be classified as indirect costs and, subsequently, apportioned among all cost centers9.It is a cost analysisThe cost was estimated in relation to the user and the service. Regarding the user, the estimate was made by dividing the total cost (direct and indirect) by the total number of users served in the year. Regarding the service, the estimate considered individual and collective practices. In the first ones, the service of a user by a therapist is considered, that is, a 1:1 ratio. In the second ones, each therapeutic group was estimated at 10 users per service, with 1 therapist for 10 users. This estimate was made according to the direct observation of the researchers and through the reports of the professionals of the unit, which was built exclusively to offer TCIM, meeting the specificities of these practices.The individual practices include: acupuncture; auriculotherapy; homeopathy; phytotherapy; art therapy; floral therapy; chiropractic; reiki; aromatherapy; massage therapy; Ayurvedic therapy and massage; foot reflexology and naturology, which also includes iridology and geotherapy. As for the collective ones, they are summarized in: biodance; circular dances; Tai Chi Chuan; community therapy; yoga; taking care of the caregiver; preventive self-massage; art therapy; healing through self-expression (plastic arts); meditation; corporal conscience; family constellation; dance of the sacred feminine and circle of pregnant women.Data were collected between 2015 and 2016, referring to 2014, as it is the last complete year at the beginning of the research. Data were obtained through the analysis of documents and other electronic cost records, in addition to direct observation of the physical area of the service, resources, activities developed and interviews with professionals and managers of the unit (Chart).The data collected were grouped into three costing centers: productive, administrative and auxiliary. This definition was based on the purpose of each sector and its relationship with services produced and offered to SUS users.The productive costing center consisted of 8 offices, a compounding pharmacy, 5 rooms for collective practices, a toy library and the auditorium. The administrative costing center consisted of a warehouse, reception room, administration room, board and meeting room. The auxiliary costing center was defined by sectors that served as support for the operational operation: 2 break rooms, bathrooms, Medical and Statistical Archive Service (MSAS), service area, kitchen, pantry, storage of cleaning material.The reception/security service was not allocated in the cost centers, being identified as an indirect cost. The utility room, the internal garden and building expenses also fell into this category.TCIM services are characterized by the low use of equipment with high technological density. In this sense, professionals have an important share of costs. At the unit, 47 employees are responsible for the operation of the service, 31 of which are allocated to the productive costing center, 8 to the administrative and 4 to the auxiliary. The reception/security service is represented by three professionals. The greatest concentration of the employees is in the productive sector, with emphasis on holistic therapists, with 11 representatives, who offer individual and collective assistance in various specialties.Apuração dos custos das medicinas/práticas integrativas e complementares na saúde mental em Pernambuco , Called MTCI/CNPq/MS-SCTIE-Decit no. 07/2013, approved by the CAAE Ethics Committee: 07270212.4. 0000.5208.This study is part of the project In the assessment of the production in 2014, there was an increase of 48.82% in the opening of medical records in relation to the previous year. Collective service also grew by 102.96%, totaling 26,479 users in the year. In individual practices, there was a reduction of 184 appointments compared with 2013, with 8,042, totaling 34,521 users treated in the year.Among individual practices, acupuncture was the most used, with 3,122 visits, followed by flower therapy, with 1,114, and chiropractic, with 638.When considering unit costs, with their due depreciation, the unit cost amount was estimated at R$ 1,270,015.70 in 2014. According to the classification adopted in this study, direct costs were responsible for R$ 1,012,140.45 (79.7%) of the total expenses of the health unit; and indirect costs, for R$ 257,875.24 (20.3%). Direct costs were subdivided into: human resources – , representing the salaries of professionals, added to all labor obligations ; depreciation of machinery, equipment and furniture  and consumables  .Of the estimated consumption material, the largest portion refers to break room, cleaning and hygiene supplies. The inputs used within the productive costing center had less contribution. The provision of services in the unit is characterized by the user/therapist relationship, without the need for many inputs besides essential oils, acupuncture needles, essences, procedure gloves and medicinal plants.10, the cost of the property was R$ 109,527.60 in the period studied. Building costs are also represented by expenses with water/sewage and electricity, estimated at R$ 114,221.76 in 2014. Expenses related to the Urban Property Tax (IPTU) and garbage collection are also part of the building costs; however, this study disregarded them, since the unit is exempt from these taxes for being a public institution. The professional activities that are part of the indirect costs are related to the safety of the health unit. Expenses related to these workers comprise 12.22%  of indirect costs  comprise building costs, in which the greatest impact is related to the depreciation of the property. The building had an estimated value of R$ 2,738,190.00; considering the depreciation rate for this type of investment at 4%ct costs  and relaThe unit’s total cost for providing services was R$ 1,270,015.70 in 2014, with a monthly average of R$ 105,834.64. Collective practices accounted for 76.70% of the total attendances and, consequently, individual practices accounted for 23.30%.The distribution of direct costs by costing center was made based on the allocation of human resources in the respective centers, since personnel expenses represented the greatest impact in this category. The productive costing center gathers most professionals (31), which is why it had a greater impact on the unit’s costs (57.75%) .The criterion chosen to apportion the indirect costs between the costing centers was the number of rooms (spaces) in the TCIM service, considering that the indirect costs are related to the acquisition and maintenance of the building infrastructure, such as property depreciation, expenses with water supply and electricity. The service in question has 29 spaces, including offices, auditoriums, bathrooms, meeting room, among others. As for the distribution of spaces, the productive costing center is responsible for the largest number of rooms, with 14 of them, followed by the auxiliary center, with 10, and the administrative center, with 5. Considering this, 48.27% of the unit’s indirect costs were allocated to the productive costing center .The distinction between individual and collective practices was considered to estimate the cost of care in this service. The average cost of user service was R$ 36.79. This allowed us to identify that the service in collective practices represents about 13% of the estimated average value per user of individual practices .11. The few services with these characteristics have a “provisional” character and low institutionality12, which directly interferes with their financing. The Ministry of Health estimate is that 25% of Brazilian municipalities have services that offer TCIM, mainly inserted in Primary Health Care (PHC) (78%), specifically in the Family Health Strategy (FHS), and only 18% are insert into specialized care13. Despite this scenario, no studies that specifically addressed the costs of TCIM in SUS were found, a fact that may discourage managers from implementing such services in the public network.The unit analyzed was structured exclusively to offer TCIM and, thus, portrayed all the costs involved in individual and collective care in TCIM in SUS. The planning and implementation process for this service was carried out by the municipal management, despite the existence of a gap in Brazilian municipalities regarding public policies on financing, implementation and sustainability of these units and their role in the Health Care Network16. This characteristic can be strategic, as it is effective without being directly connected to the use of high technologies and, therefore, has more potential to reduce costs. The training of professionals in the field of TCIM is an important gap for the development of other health rationales in SUS. Despite this reality, it is essential that studies on the effectiveness of TCIM address the costs of inputs and their economic results17.The most relevant costs for the operation of the service were employees’ salaries and their respective employer’s charges, reflecting the reality of most health services16.The unit value of R$ 36.79 per service is considered compatible with biomedical services of medium complexity; however, the service provided in TCIM is also characterized by being resolutive and does not generate extra demands, such as specialized exams and other invasive procedures, in addition to those performed during the service. Despite this, this field is also part of a scenario marked by lack of resources and unlimited demand, requiring sustainable financing and management mechanisms. With a similar methodology (absorption costing), the cost of an outpatient appointment was estimated at R$ 36.24, in a state maternity hospital in Santa Catarina. The costs are compatible with those of the service at the TCIM unit, even considering peculiarities inherent to both studies, such as complexity of equipment, supplies, apportionment criteria and purpose of services18. The Chinese traditional medicine has been cost-effective for health systems and insurances19. We found that acupuncture reduces referrals to physical therapy and rheumatology in the primary health care services where it was introduced22.The cost-effectiveness of TCIM is documented only in the international literature. A Dutch study showed that users had fewer hospitalizations and prescription drugs and lower expenses with general practitioners who perform homeopathy, acupuncture and anthroposophy23.To establish stages of opening, maintenance and dimensioning health units specialized in TCIM, it is essential to analyze the costs in order to identify the investment necessary to offer these services. Cost management is part of the efficient management of any entity that offers services or products, whether in the private or public sphereThe service is characterized by low technological density, with raw material that requires little expenditure of financial resources. The data were verified with the analysis of the investment and consumption materials of the productive costing center, in which the greatest financial impact is caused by human resources.The result of the cost assessment needs to consider the integral and holistic approach adopted in the TCIM. Studies on cost-effectiveness can contribute to expand and contextualize the characteristics of health care in this field. Economic assessments are recommended, such as cost-effectiveness, which aims to assess the relationship between what is spent and the effectiveness of TCIM for SUS users.The consolidation of innovative policies, such as the TCIM offer, is directly influenced by the disclosure of the indications and effectiveness of these practices. The aim is to increase the number of users and professionals who know its benefits, either through direct access or through professional referral to services of this nature. Initiatives like these can dilute the cost per user of TCIM, since units aimed at such services have a high fixed cost.24. In fact, this has occurred in the provision of TCIM in PHC, but it needs a back-up network to receive due support. According to the study by Sousa & Tesser11, the type 3 insertion model (PHC with matrix support) is one of the potential ways of expanding MTCI in SUS. In the national and international literature, the discussion is scarce about the costs of implantation and maintenance of health units specialized in TCIM, given they have financing through outpatient production. Recent research found three exclusive units in TCIM in Brazil, two in Recife (Pernambuco) and another in João Pessoa (Paraíba)1. These are important cases for professionals and managers to understand aspects of their implementation and financial sustainability.The organizational structure experienced in some countries, such as the USA, which host TCIM and biomedical services in the same physical space, can be a strategy in Brazil according to each local context, given the lack of resources in many municipalities to implement an exclusive unitAt the time of the study, different individual and collective practices offered were not part of the scope of institutionalized care in SUS, which changed with the publication of two ordinances, which may alter the registered production. But since financing has not been guaranteed, this fact is unlikely to change revenue collection. Therefore, TCIM continues in Brazil without specific investment or inducing resources.9. A study carried out with private hospitals in João Pessoa (Paraíba) found that only 10% of the sample’s managers shared all the indirect costs25.The arbitrariness during the appropriation and apportionment of indirect costs is another factor that makes it difficult to compare studies, being common in cost management. This happens, most of the time, due to the lack of knowledge of managers or the lack of apportionment parameters, especially when it comes to services that provide different servicesThis fact is ratified by this study, which has as a limitation the impossibility of accurately apportioning indirect costs, due to the lack of available data. Another limitation is the estimate of 10 users per group of collective practice, since this number was estimated empirically, not statistically.TCIM is an emerging and complex field, with varying acceptance within society and the scientific community. Although public policies and studies subsidize their use in a formal way, the implementation of these practices remains irregular and little disseminated in SUS, with important gaps to be filled in the health economy. This study can support further deepening and analysis in this regard. 1 em vários sistemas de saúde do mundo tem ampliado a discussão acerca dos seus custos e possibilidade de integração. O reconhecimento social, institucional e acadêmico das MTCI reforça a ideia de que o modelo biomédico convive com outras formas de cuidado, em um contexto cultural caracterizado pelo pluralismo terapêutico3.A crescente inserção das Medicinas Tradicionais, Complementares e Integrativas (MTCI)4. No Brasil, são chamadas no Sistema Único de Saúde (SUS) de Práticas Integrativas e Complementares em Saúde (PICS)1, provenientes de diferentes racionalidades em saúde. A oferta das PICS no SUS tem se ampliado recentemente, totalizando 29 práticas provenientes de sistemas complexos ou recursos terapêuticos, sendo: homeopatia, fitoterapia/plantas medicinais, acupuntura/medicina tradicional chinesa, medicina antroposófica, termalismo social/crenoterapia, arteterapia, ayurveda, biodança, dança circular, meditação, musicoterapia, naturopatia, osteopatia, quiropraxia, reflexoterapia, reiki, shantala, terapia comunitária integrativa, yoga, aromaterapia, apiterapia, bioenergética, constelação familiar, cromoterapia, geoterapia, hipnoterapia, imposição de mãos, ozonioterapia e terapia de florais5.As MTCI enfocam a abordagem integral do ser humano, reunindo os sistemas físico, psicológico, cultural e socialTal ampliação de oferta merece análises mais aprofundadas e estudos no campo da avaliação econômica que subsidiem a tomada de decisão no SUS acerca deste tema.1. Isso ocorre devido a vários fatores, tais como: ausência de profissionais capacitados, falta ou insuficiência de recursos financeiros indutores para implantar e manter os serviços e baixo conhecimento acerca dos custos e da efetividade desses serviços6.Essa realidade proporciona subsídios para o surgimento de novos serviços dentro do SUS que respondam aos anseios dos usuários, dos profissionais e gestores de saúde, bem como da comunidade científica. No entanto, as MTCI são fragilmente institucionalizadas e distribuídas de forma heterogênea no país7. Dados os seus limites, essa avaliação pode subsidiar o investimento na qualidade da assistência à medida que permite realocar e otimizar recursos. No que se refere aos serviços de MTCI, esse paralelo com a contabilidade de custos é pouco documentado, o que gera distorções administrativas e dificuldade de estimar o valor do serviço e/ou procedimentos de MTCI para o SUS. Considerando o cenário de ausência de produção científica que enfoque os custos em MTCI, o estudo que gerou este manuscrito teve por objetivo estimar os custos de um serviço especializado em MTCI no Nordeste brasileiro.A administração pública tem demonstrado tendência para uma gestão mais profissionalizada, com avaliação de custos. Essa visão de eficiência gerencial tem sido implantada nas instituições públicas de saúde8 a partir da perspectiva da gestão pública, utilizando o custeio por absorção de uma unidade pública especializada em MTCI, com oferta de práticas individuais e coletivas diferenciadas e produção de insumos terapêuticos, localizada em João Pessoa (PB). O método de custeio por abrsorção visa identificar os custos como diretos, uma vez que os agrupa em centros que dependem destes para realizar suas atividades-fim. Apenas itens que não podem ser exclusivamente alocados nos respectivos centros de custo serão classificados como custos indiretos e, posteriormente, rateados entre todos os centros de custo9.Trata-se de uma análise de custosO custo foi calculado em relação ao usuário e ao atendimento. No que tange ao usuário, o cálculo foi feito dividindo o custo total (direto e indireto) pelo total de usuários atendidos no ano. Em relação ao atendimento, o cálculo considerou práticas individuais e coletivas. Nas primeiras, considera-se o atendimento de um usuário por terapeuta, ou seja, a relação é de 1 para 1. Nas segundas, cada grupo terapêutico foi estimado em 10 usuários por atendimento, sendo 1 terapeuta para 10 usuários. Essa estimativa foi realizada de acordo com a observação direta dos pesquisadores e por meio dos relatos dos profissionais da unidade, a qual foi construída exclusivamente para oferecer MTCI, atendendo às especificidades dessas práticas.Dentre as práticas individuais ofertadas estão: acupuntura; auriculoterapia; homeopatia; fitoterapia; arteterapia; terapia floral; quiropraxia; reiki; aromaterapia; massoterapia; terapia e massagem ayurvédica; reflexologia podal e naturologia, que também inclui iridologia e geoterapia. Quanto às coletivas, resumem-se em: biodança; danças circulares; tai chi chuan; terapia comunitária; yoga; cuidando do cuidador; automassagem preventiva; arteterapia; cura em expressão (artes plásticas); meditação; consciência corporal; constelação familiar; dança do sagrado feminino e círculo de gestantes.A coleta de dados foi realizada entre 2015 e 2016, referente ao ano de 2014, por se tratar do último ano completo no início da pesquisa. Os dados foram obtidos por meio da análise de documentos e outros registros eletrônicos de custos, além da observação direta da área física do serviço, dos recursos, das atividades desenvolvidas e entrevista com os profissionais e gestores da unidade .Os dados coletados foram agrupados em três centros de custeio: produtivo, administrativo e auxiliar. Essa definição teve por base a finalidade de cada setor e sua relação com serviços produzidos e oferecidos aos usuários do SUS.O centro de custeio produtivo era composto por 8 consultórios, farmácia de manipulação, 5 salas de práticas coletivas, brinquedoteca e o auditório. O centro de custeio administrativo era constituído por almoxarifado, sala de recepção, sala de administração, diretoria e sala de reuniões. O centro de custeio auxiliar foi definido por setores que serviam como suporte para o funcionamento operacional: 2 copas, banheiros, Serviço de Arquivo Médico e Estatístico (Same), área de serviço, cozinha, despensa, depósito de material de limpeza.O serviço de portaria/segurança não foi alocado nos centros de custos, sendo identificado como custo indireto. A sala de utilidade, o jardim interno e as despesas prediais também se enquadraram nessa categoria.Os serviços de MTCI têm como característica o baixo uso de equipamentos com alta densidade tecnológica. Nesse sentido, os profissionais têm importante participação nos custos. Na unidade, 47 funcionários são responsáveis pelo funcionamento do serviço, sendo 31 alocados no centro de custeio produtivo, 8 no administrativo e 4 no auxiliar. O serviço de portaria/segurança é representado por 3 profissionais. A maior concentração dos funcionários da unidade está no setor produtivo, com destaque para os terapeutas holísticos, com 11 representantes, que oferecem atendimentos individuais e coletivos em diversas especialidades.Este estudo faz parte do projeto “Apuração dos custos das medicinas/práticas integrativas e complementares na saúde mental em Pernambuco – ApuraSMPIC”, Chamada MTCI/CNPq/MS-SCTIE-Decit nº 07/2013, aprovado no Comitê de Ética CAAE: 07270212.4.0000.5208.Na avaliação da produção no ano de 2014, observou-se acréscimo de 48,82% na abertura de prontuários em relação ao ano anterior. Os atendimentos coletivos também cresceram, em 102,96%, totalizando 26.479 usuários no ano. Nas práticas individuais, houve redução de 184 atendimentos em relação a 2013, com 8.042, totalizando 34.521 usuários atendidos no ano.Dentre as práticas individuais, a acupuntura foi a mais utilizada, com 3.122 atendimentos, seguida pela terapia floral, com 1.114, e pela quiropraxia, com 638.Ao considerar os custos unitários, com suas devidas depreciações, o montante dos custos da unidade foi estimado em R$ 1.270.015,70 no ano de 2014. De acordo com a classificação adotada neste estudo, os custos diretos foram responsáveis por R$ 1.012.140,45  do total de despesas da unidade de saúde; e os indiretos, por R$ 257.875,24 . Os custos diretos foram subdivididos em: recursos humanos – , representando os salários dos profissionais, somados a todas as obrigações trabalhistas ; depreciação de máquinas, equipamentos e móveis  e materiais de consumo  .Do material de consumo estimado, a maior parcela é referente a insumos da copa, limpeza e higiene. Os insumos utilizados dentro do centro de custeio produtivo tiveram contribuição menor. A prestação de serviços na unidade é caracterizada pela relação usuário/terapeuta, sem a necessidade de muitos insumos além de óleos essenciais, agulhas de acupuntura, essências, luvas de procedimento e plantas medicinais.10, o custo do imóvel foi de R$ 109.527,60 no período estudado. Os custos prediais também são representados por despesas com água/esgoto e energia elétrica, estimadas em R$ 114.221,76 em 2014. Despesas relacionadas ao Imposto Predial e Territorial Urbano (IPTU) e à coleta de lixo também fazem parte dos custos prediais, entretanto, esse estudo os desconsiderou, visto que a unidade é isenta desses impostos por se tratar de uma instituição pública. As atividades profissionais que fazem parte dos custos indiretos estão relacionadas à segurança da unidade de saúde. As despesas referentes a esses trabalhadores englobam 12,22%  dos custos indiretos  compreendem os custos prediais, nos quais o maior impacto está relacionado à depreciação do imóvel. O prédio teve o valor estimado em R$ 2.738.190,00; levando em consideração a taxa de depreciação para esse tipo de investimento em 4%ndiretos  e dizem O custo total de prestação de serviços da unidade foi de R$ 1.270.015,70 no ano de 2014, com média mensal de R$ 105.834,64. As práticas coletivas representaram 76,70% do total de atendimentos e, consequentemente, as práticas individuais representaram 23,30%.A distribuição dos custos diretos por centro de custeio foi realizada a partir da alocação dos recursos humanos nos respectivos centros, visto que os gastos com pessoal representaram o maior impacto nessa categoria. Constatou-se que o centro de custeio produtivo reúne a maior parte dos profissionais (31), por isso teve maior impacto nos custos da unidade  .O critério escolhido para ratear os custos indiretos entre os centros de custeio foi a quantidade de salas (espaços) no serviço de MTCI, tendo em vista que os custos indiretos estão relacionados à aquisição e manutenção da infraestrutura predial, tais como depreciação do imóvel, gastos com abastecimento hídrico e energia elétrica. O serviço em questão possui 29 espaços, incluindo consultórios, auditórios, banheiros, sala de reunião, entre outros. Quanto à distribuição de espaços, o centro de custeio produtivo é responsável pela maior quantidade de salas, com 14 delas, seguido pelo centro auxiliar, com 10, e pelo administrativo com 5. Diante disto, 48,27% dos custos indiretos da unidade foram alocados ao centro de custeio produtivo .Considerou-se a distinção entre práticas individuais e coletivas para estimar o custo do atendimento neste serviço. O custo médio do atendimento ao usuário foi de R$ 36,79. Isso permitiu identificar que o atendimento em práticas coletivas representa cerca de 13% do valor médio estimado por usuário de prática individual .11. Os poucos serviços com estas características possuem caráter “provisório” e de baixa institucionalidade12, o que interfere diretamente no seu financiamento. A estimativa do Ministério da Saúde é que 25% dos municípios brasileiros possuem serviços que ofertam MTCI, principalmente inseridos na Atenção Primária à Saúde (APS) (78%), especificamente na Estratégia de Saúde da Família (ESF), e apenas 18% se inserem na atenção especializada13. Mesmo diante desse cenário, não foram encontrados estudos que tratassem especificamente dos custos das MTCI no SUS no Brasil, fato que pode desencorajar gestores a implantar tais atendimentos na rede pública.A unidade analisada estruturou-se exclusivamente para ofertar MTCI e, desta forma, retratou todos os custos envolvidos no atendimento individual e coletivo em MTCI no SUS. O processo de planejamento e implantação desse serviço foi executado pela gestão municipal, apesar de existir uma lacuna nos municípios brasileiros quanto às políticas públicas que versam sobre financiamento, implantação e sustentabilidade dessas unidades e a sua função na Rede de Atenção à Saúde16. Essa característica pode ser estratégica, pois produz efetividade sem estar diretamente conectada com o uso de altas tecnologias e, portanto, tem mais potencial de reduzir custos. A formação de profissionais no campo da MTCI constitui uma importante lacuna para o desenvolvimento de outras racionalidades em saúde no SUS. Apesar dessa realidade, é essencial que os estudos que versam sobre a efetividade da MTCI tratem dos custos dos insumos e dos seus resultados econômicos17.Os custos mais relevantes para o funcionamento do serviço foram com salários dos funcionários e seus respectivos encargos patronais, refletindo a realidade da maioria dos serviços de saúde16.O valor unitário de R$ 36,79 por atendimento é considerado compatível com serviços biomédicos de média complexidade, entretanto, o atendimento efetuado em MTCI também é caracterizado por ser resolutivo e não gerar demandas extras, como exames especializados e outros procedimentos invasivos, além dos realizados no ato do atendimento. Apesar disso, esse campo também faz parte de um cenário marcado por escassez de recursos e demanda ilimitada, necessitando de mecanismos sustentáveis de financiamento e gestão. Com metodologia semelhante (custeio por absorção), estimou-se o custo de uma consulta ambulatorial em R$ 36,24, em uma maternidade estadual de Santa Catarina. Os custos são compatíveis com os do atendimento na unidade de MTCI, mesmo considerando peculiaridades inerentes aos dois estudos, como complexidade de equipamentos, insumos, critérios de rateio e finalidade dos serviços18. A medicina tradicional chinesa tem sido custo-efetiva para os sistemas e seguros de saúde19. Constatou-se que a acupuntura diminui os encaminhamentos para fisioterapia e reumatologia nos serviços de atenção primária em saúde em que foi introduzida22.O custo-efetividade da MTCI é documentado apenas na literatura internacional. Um estudo holandês evidenciou que usuários tiveram menos internações e prescrição de drogas e menores despesas com médicos generalistas que realizam homeopatia, acupuntura e antroposófia23.Para estabelecer etapas de abertura, manutenção e dimensionamento de unidades de saúde especializadas em MTCI é imprescindível analisar os custos, a fim de identificar o investimento necessário para ofertar esses serviços. O gerenciamento dos custos faz parte da gestão eficiente de qualquer entidade que ofereça serviços ou produtos, seja no âmbito privado ou públicoO serviço tem como característica a baixa densidade tecnológica, com matéria-prima que requer pouco dispêndio de recursos financeiros. Esse dado foi constatado com a análise dos materiais de investimento e de consumo do centro de custeio produtivo, no qual o impacto financeiro maior é causado pelos recursos humanos.O resultado da avaliação do custo precisa considerar a abordagem integral e holística adotada nas MTCI. Estudos sobre custo-efetividade podem contribuir para ampliar e contextualizar as características do cuidado em saúde nesse campo. Recomendam-se avaliações econômicas como a de custo-efetividade, que tem o intuito de aferir a relação entre o que se gasta e a efetividade das MTCI para o usuário do SUS.A consolidação de políticas inovadoras, como a oferta de MTCI, é influenciada diretamente pela divulgação das indicações e efetividade dessas práticas. O intuito é ampliar o número de usuários e profissionais que conhecem seus benefícios, seja pelo acesso direto ou por meio de encaminhamento profissional para serviços dessa natureza. Iniciativas como essas podem diluir o custo por usuário de MTCI, visto que unidades voltadas a tais atendimentos apresentam um custo fixo alto.24. De fato, isso tem ocorrido na oferta de MTCI na APS, mas esta necessita de uma rede de retaguarda para receber o devido apoio. Conforme o estudo de Sousa e Tesser11, o modelo de inserção tipo 3 (APS com matriciamento) é uma das formas potenciais de expansão da MTCI no SUS. Na literatura nacional e internacional a discussão é escassa sobre os custos de implantação e manutenção de unidades de saúde especializadas em MTCI, haja vista o fato de terem financiamento via produção ambulatorial. Pesquisa recente encontrou três unidades exclusivas em MTCI no Brasil, duas em Recife (PE) e outra em João Pessoa (PB)1. Trata-se de casos importantes para profissionais e gestores compreenderem aspectos de sua implantação e sustentabilidade financeira.A estrutura organizacional vivenciada em alguns países, como os EUA, que abrigam os serviços de MTCI e biomédicos no mesmo espaço físico, pode ser uma estratégia no Brasil de acordo com cada contexto local, haja vista a falta de recursos em muitos municípios para implantar uma unidade exclusivaNa época do estudo, diferentes práticas individuais e coletivas ofertadas não faziam parte do escopo de atendimentos institucionalizados no SUS, o que se modificou com a publicação de duas portarias, as quais poderão alterar a produção registrada. Mas como não foi garantido financiamento, este fato provavelmente não vai alterar a captação de receitas. Portanto, as MTCI seguem no Brasil sem investimento específico ou recurso indutor.9. Estudo realizado com hospitais privados em João Pessoa (PB) verificou que apenas 10% dos gestores da amostra rateava a totalidade dos custos indiretos25.A arbitrariedade durante a apropriação e o rateio dos custos indiretos é outro fator que dificulta a comparação entre estudos, sendo recorrente na gestão de custos. Isso acontece, na maioria das vezes, por desconhecimento dos gestores ou por falta de parâmetros de rateio, principalmente quando se trata de serviços que prestam atendimentos distintosTal fato é ratificado por este estudo, que apresenta como limitação a impossibilidade de ratear de forma precisa os custos indiretos, devido à escassez de dados disponíveis. Outra limitação identificada refere-se à estimativa de 10 usuários por grupo de prática coletiva, uma vez que este número foi estimado de forma empírica, não estatística.A MTCI constitui um campo emergente e complexo, com aceitação variada dentro da sociedade e da comunidade científica. Apesar de políticas públicas e estudos subsidiarem sua utilização de maneira formal, a implantação dessas práticas permanece irregular e pouca difundida no SUS, com importantes lacunas a serem preenchidas na economia da saúde. Acredita-se que este estudo pode subsidiar novos aprofundamentos e análises nesse sentido.


Instead of “2 Charité—Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany, 3 Berlin Institute of Health, Pharmakovigilanz- und Beratungszentrum für Embryonaltoxikologie, Institut für Klinische Pharmakologie und Toxikologie, Berlin, Germany,” it should be “2 Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institut für Klinische Pharmakologie und Toxikologie, Pharmakovigilanz- und Beratungszentrum für Embryonaltoxikologie, Berlin, Germany.”In the published article, there was an error in affiliations The authors apologize for this error and state that this does not change the scientific conclusions of the article in any way. The original article has been updated.


Transarterial radioembolization (TARE) with yttrium-90 microspheres is a palliative locoregional treatment, minimally invasive for liver tumors. The neoadjuvant aim of this treatment is still controversial, however, selected cases with lesions initially considered unresectable have been enframed as candidates for curative therapy after hepatic transarterial radioembolization. We report three cases in which the hepatic transarterial radioembolization was used as neoadjuvant therapy in an effective way, allowing posterior potentially curative therapies. Diagnosis and curative treatment are only possible for minority of patients, and a number of palliative treatment modalities seem to be the best therapeutic proposals indicated for treatment of most of patients.   , 4 , 5  The neoadjuvant objective of this treatment is still controversy, but selected cases of injures initially considered unresectable, when undergoing TARE, are reclassified as candidates to the curative therapy.   , 6 , 7 Transarterial radioembolization (TARE) of the liver with yttrium-90 microspheres constitutes a minimally invasive locoregional palliative treatment modality. In general, indication for this procedure occurs due to progression of liver lesions, in cases of failure with conventional systemic therapy, surgical therapy (resection or transplantation) or even other locoregional modalities, such as chemoembolization or ablation. To report 3 cases of liver tumors in which transarterial radioembolization of the liver was used as a neoadjuvant therapy.A 68-year-ol man with multinodular hepatocellular carcinoma who previously underwent TARE, radiofrequency ablation and who were not within liver transplantation criteria, and who downstaging therapy did not work   . After A 35-year-old woman with unresectable cholangiocarcinoma involving the right and medium liver veins, and live remanescent of 23%    . She unIn the late follow-up of 9 months, we did not observe right liver vein invasion with reminiscent of 63% of the liver   , enabliA 59-year-old man with hepatitis C virus and voluminous hepatocellular carcinoma (7.5cm) involving segments IVa/VIII   . He was  In a series by Mohamed et al., comparing four different therapeutic modalities as a bridge for liver transplantation, notably TARE was effective, therefore, as the remaining, with lower advantages and lower acute toxicity (such as the stereotactic radiotherapy), enabling transplantation in patients with large in diameters injuries.   In 2011, Ettore et al., published a case report including patients in stages B and C at Barcelona Clinic Liver Cancer (BCLC) and who were not within the Milan criteria. They obtained a conversion for liver transplantation by 11%, in which we treated with TARE, initially as a palliative modality only.   In systematic review, Braat et al., presented studies that showed evidences of benefits of neodjuvant use of TARE in intra-hepatic colangiocarcinoma, in addition to hepatocarcinoma. There were no cases of progression of the disease during time of waiting for surgical intervention. All patients reported to be with an accompanying person  and without recurrent of the disease.  , 10 In our cases, TARE was an effective therapy, combining simultaneously the antitumor effect (cytotoxicity induced by radiation) and ischemic effect with hypertrophy of non-embolized segments, and enabling the posterior employment of potentially curative therapies.    - 3 A radioembolização transarterial hepática (TARE) com microesferas de ítrio-90 é uma modalidade paliativa de tratamento locorregional minimamente invasiva. A indicação, em geral, ocorre diante da progressão das lesões hepáticas, a despeito do uso da terapia sistêmica convencional, terapia cirúrgica (ressecção ou transplantes) ou mesmo outras modalidades locorregionais, como quimioembolização ou ablação.  , 4 , 5 O objetivo neoadjuvante deste tratamento ainda é controverso, mas casos selecionados de lesões consideradas inicialmente irressecáveis ao submeterem-se à TARE reenquadram-se como candidatos à terapia curativa.  , 6 , 7 As neoplasias hepáticas primárias e secundárias são importante causa de mortalidade relacionada ao câncer. Ao diagnóstico, o tratamento curativo somente é possível em uma minoria destes pacientes, e as diversas modalidades paliativas de tratamento parecem ser as propostas terapêuticas melhores indicadas na condução da maioria destes pacientes.Relatar três casos de tumores do fígado em que a radioembolização transarterial hepática foi utilizada como terapia neoadjuvante.downstaging    . SubmetPaciente do sexo masculino, 59 anos, hepatite vírus C e volumoso hepatocarcinoma  envolvendo os segmentos IVa/VIII   . Foi tr  Mohamed et al., em sua série comparando quatro diferentes modalidades terapêuticas como ponte para transplante hepático, notaram que a TARE foi efetiva, assim como as demais, com a vantagem de menor toxicidade aguda (tanto quanto a radioterapia estereotática), possibilitando o transplante nos pacientes com lesões de maiores diâmetros.Barcelona Clinic Liver Cancer (BCLC) B e C fora dos critérios de Milão, obtendo conversão para o transplante hepático em 11%, os quais foram tratados com TARE, inicialmente apenas como modalidade paliativa.  Em 2011, Ettore et al., publicaram sua casuística de pacientes nos estágios   Em revisão sistemática, Braat et al., apresentaram estudos que apontam evidências do benefício do uso neoadjuvante da TARE no colangiocarcinoma intra-hepático e nas metástases hepáticas, além do hepatocarcinoma.Não houve casos de progressão de doença durante o tempo de espera para intervenção cirúrgica. Todos os pacientes relatados estão em acompanhamento  e sem recidiva de doença.  , 10 Em nossos casos, a TARE foi uma terapia efetiva, combinando simultaneamente o efeito antitumoral (citotoxicidade induzida pela radiação) e o efeito isquêmico com hipertrofia dos segmentos não embolizados, possibilitando o emprego posterior de terapias potencialmente curativas.


Agaricus bisporus ) pizza. He denied any drug intake, hymenoptera stings or other possible triggers, and no identifiable cofactors were present. Since then he avoided all types of mushrooms, however an accidental contact occurred with mushroom sauce that resulted in angioedema of the lip within minutes. The allergy workup included measurements of total IgE and specific IgE to mushroom, and skin prick test to aeroallergens sources, possible food allergen sources and mushroom extract, a prick to prick test with raw and cooked A. bisporus , in addition to a SDS-PAGE and immunoblotting assay. The study revealed a specific IgE to mushroom of 0.76kUA/L positive skin prick test to mushroom extract, and prick to prick test positive to white and brown A. bisporus (raw and cooked). The immunoblotting identified two IgE binding proteins with 10kDa and 27kDa. We report a case of A. bisporus anaphylaxis probably due to primary mushroom sensitization. We detected two IgE-reactive proteins with 10kDa and 27kDa as possible culprit allergens.A 33-year-old male with house dust mite allergic rhinitis and asthma reported an episode of facial and lip angioedema, dyspnea, cough and dysphagia at the age of 25, minutes after eating a mushroom (  Anaphylaxis is a serious allergic reaction with a rapid onset and potentially fatal outcome.In adults the main anaphylaxis triggers are food, insect stings and drugs. In a suspected food allergy, a clinical history with a food diary is extremely important to identify unusual food allergens.Concerning food allergens, the main identified triggers are peanut, fish, shellfish, tree nut and fresh fruits, especially in pollen allergic patients; however we must be aware that the implicated allergens can change with different eating patterns.Species in the Fungi kingdom can cause different types of allergic symptoms. Allergens from mold spores are mainly associated with airborne respiratory allergies. Mushroom species can be implicated in contact dermatitis and also cause digestive symptoms, accounting for 1% of mushroom allergy.Agaricus bisporus is the largest cultivated mushroom, accounting for 38% of the world production. Only few cases of allergy due to ingestion of A. bisporus have been described. The majority of cases reporting mushroom allergy due to ingestion refer to the species Boletus edulis , Boletus badius , Lentinus edulus and Tricholoma matsutake.A. bisporus in a patient without any other sensitization to molds, in which ingestion appears to be the primary route of sensitization.We report a case of anaphylaxis to Dermatophagoides pteronyssinus and Dermatophagoides farinae .A 33-year-old man with allergic rhinitis and asthma under treatment with inhaled and nasal corticosteroids, and with a known allergy to He experienced an anaphylactic reaction at the age of 25 years, with facial and lip angioedema, dyspnea, cough and dysphagia minutes after ingestion of a mushroom pizza. No other suspected triggers were present, such as drug intake or stings. He also denied physical exercise or alcohol intake in the hours before the episode. He stopped eating mushrooms and any food containing mushrooms.The patient reported two posterior episodes of lip angioedema, without any other symptoms after accidental contact with mushroom sauce.D. pteronyssinus , D. farina e, Lepidoglyphus destructor , cat and dog dander) molds  and mushroom were carried out.Measurements of serum total IgE  and specific IgE  to airborne allergenic sources ( D. pteronyssinus (100HEP/mL); D. farinae (100HEP/mL); L. destructor (10HEP/mL); pollens from Olea europaea (30HEP/mL), Corylus avellana (30HEP/mL), and Platanus occidentalis (30HEP/mL); cat and dog dander (30HEP/mL); A. fumigatus (150ug protein/mL); A. alternata (30HEP/mL); Cladosporium herbarum (150ug protein/mL); Candida albicans (125ug protein/mL); pollen from grass mixture (30HEP/mL); cow's milk , egg ; wheat flour ; tomato (10HEP/mL) and mushroom (10HEP/mL). Histamine was used as positive control (10mg/mL).We also performed skin prick tests with commercial extracts  of A. bisporus was also carried out.Besides skin testing with commercially available extracts, a prick to prick test with raw and cooked A. bisporus .A sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) immunoblotting assay was performed to assess the molecular mass of the IgE-binding proteins from A/L), D. peteronyssinus (30.90kUA/L) and L. destructor (2.33kUA/L).Total IgE was 240kU/L and specific IgE was positive to mushroom (0.76kUD. pteronyssinus (10mm), D. farinae (8mm), L. destructor (7mm).Skin prick tests were positive to extracts from mushroom (7mm), A. bisporus , and raw (14mm) and cooked (11mm) brown A. bisporus ( Prick to prick test was positive to raw (9mm) and cooked (11mm) white isporus   .A. bisporus extract revealed two main IgE binding bands of approximately 10kDa and 27kDa ( The immunoblotting assay with d 27kDa   .(-)In the literature there are a few cases of mushroom food allergy, most of them occurred in China, where mushrooms are included in the diet and the last known report was published in 2013.A. bisporus allergy in a patient with asthma and rhinitis, an uncommon case highlighting the importance of being aware of unsuspected food allergens.We report a case of anaphylaxis due to A. alternata , who had one episode of exercise-induced anaphylaxis after ingestion of A. bisporus ; Dauby et al. described a woman with allergic rhinitis, allergic to Hormodendrum cladosporioides , A. alternata , Fusarium vasinfectum , Helminthosporium interseminatum and to Epicoccum nigrum , with an oral allergy syndrome to raw A. bisporus, and in both case reports the authors believed the hypersensitivity reaction was attributable to cross reactivity between mold and mushroom allergens.According to skin tests and serum measurements, the patient was allergic to house dust mites and mushroom. The skin tests were negative to molds and all other suspected food allergen sources. Without mold sensitization, this patient probably presents a primary sensitization to mushroom by ingestion, and not a cross reactivity with molds or mushroom spores. The cases reported in the literature associated mushroom food allergy to cross reactivity: Carrapatoso et al. described a case of a young man with allergic rhinitis allergic to et al . were able to identify mannitol, the major carbohydrate component in Fungi , as one of the possible allergens of A. bisporus in a woman who had anaphylactic episodes, after ingestion of A. bisporus and pomegranate. Dauby et al . identified thermolabile A. bisporus proteins with molecular weight of 43kDa to 67kDa, which seemed to cross react with aeroallergens from mold, and were involved in a case similar to oral allergy syndrome.Two thermostable IgE-reactive proteins with approximately 10kDa and 26kDa were detected, although protein class was not established, and these two allergens were unknown until our case report. In other case reports other mushroom allergens were identified. Hegde After the diagnosis of mushroom allergy, the patient was advised to eliminate mushroom and mushroom-containing products from his diet. He was prescribed an adrenaline autoinjector  to use, if necessary.A. bisporus . The first episode described by the patient fulfills clinical criteria for anaphylaxis, which is rather uncommon presentation. The immunoblotting assay revealed two IgE-reactive proteins with approximately 10kDa and 27kDa.There are few described cases of mushroom food allergy, and the majority are due to cross-reactivity between molds and food allergens. The scarce data related to primary sensitization to edible mushrooms and food allergy became our diagnostic approach difficult, but make our results even more important, since our patient has a probable primary sensitization to Although a food oral challenge was contraindicated, the test results and clinical history were essential to make diagnosis. The importance of considering less common allergenic sources as possible culprits is challenging, but it is of utmost relevance in the field of food allergy. A anafilaxia é uma reação alérgica grave, com início rápido e desfecho potencialmente fatal.Em adultos, os principais desencadeadores de reações anafiláticas são alimentos, picadas de insetos e fármacos.Em casos suspeitos de alergia alimentar, a história clínica, combinada a um diário alimentar, é extremamente importante para a identificação de alérgenos alimentares menos comuns.Em relação aos alérgenos alimentares, os principais desencadeadores identificados são amendoim, peixe, crustáceos, frutos secos e frutas frescas, principalmente em pacientes alérgicos a pólen; no entanto, temos que estar cientes de que os alérgenos implicados podem mudar conforme os diferentes padrões alimentares.Espécies do reino Fungi podem causar diferentes tipos de sintomas alérgicos. Alérgenos dos esporos de bolores são predominantemente associados a alergias respiratórias. Espécies de cogumelos podem estar implicadas em dermatite de contato e causar também sintomas digestivos, que correspondem a 1% das alergias a cogumelos.Agaricus bisporus é a espécie mais cultivada de cogumelos e representa 38% da produção mundial.Foram descritos apenas raros casos de alergia por ingestão de A. bisporus . A maioria dos casos relatados de alergia após ingestão de cogumelos referem-se às espécies Boletus edulis, Boletus badius, Lentinus edulus e Tricholoma matsutake.A. bisporus num paciente sem qualquer outra sensibilização a fungos, em que a ingestão parece ser a via de sensibilização primária.Relatamos aqui um caso de anafilaxia por ingestão de Dermatophagoides pteronyssinus e Dermatophagoides farinae .Indivíduo do sexo masculino, 33 anos, com asma e rinite alérgica, em tratamento com corticosteroides inalatórios e nasais e com alergia conhecida a Apresentou reação anafilática aos 25 anos, com angioedema facial e labial, dispneia, tosse e disfagia alguns minutos após ingestão de pizza de cogumelo. Não havia qualquer outro desencadeador presente, como fármacos ou picadas de insetos. O paciente também negou ter realizado exercício físico ou consumido álcool nas horas que antecederam o episódio. Desde então, o doente evita cogumelos ou qualquer alimento contendo cogumelos.O paciente relatou dois episódios posteriores de angioedema labial, sem nenhum outro sintoma, após contato acidental com molho de cogumelo.Dermatophagoides pteronyssinus , D. farinae , Lepidoglyphus destructor , faneras de gatos e cães), bolores  e cogumelos.Foram realizados doseamentos séricos de IgE total  e IgE específico  para aeroalérgenos ( D. pteronyssinus (100HEP/mL); D. farinae (100HEP/mL); L. destructor (10HEP/mL); pólen de Olea europaea (30HEP/mL), Corylus avellana (30HEP/mL) e Platanus occidentalis (30HEP/mL); faneras de gatos e cães (30HEP/mL); A. fumigatus (150ug proteína/mL); A. alternata (30HEP/mL); Cladosporium herbarum (150ug de proteína/mL); Candida albicans (125ug de proteína/mL); pólen de gramíneas (30HEP/mL); leite de vaca (1.600ug de proteína/mL); ovos (1.400ug de proteína/mL); farinha de trigo (1.900ug de proteína/mL); tomate (10HEP/mL) e cogumelos (10HEP/mL). A histamina foi usada como controle positivo (10mg/mL).Realizamos também testes cutâneos com extratos comerciais  de prick to prick com A. bisporus cru e cozido.Além dos testes cutâneos com extratos disponíveis comercialmente, foi realizado teste immunoblotting por eletroforese em gel de poliacrilamida com dodecil sulfato de sódio (SDS-PAGE) para avaliar a massa molecular das proteínas de ligação ao IgE do A. bisporus .Foi efetuado A/L), Dermatophagoides peteronyssinus  e L. destructor .A IgE total foi de 240kU/L e a IgE específica foi positiva para cogumelos , D. farinae (8mm) e L. destructor (7 mm).Os testes cutâneos foram positivos para extrato de cogumelos (7mm), prick to prick foi positivo para A. bisporus branco cru (9mm) e cozido (11mm) e A. bisporus castanho cru (14mm) e cozido (11mm) ( O teste  (11mm)   .immunoblotting com extrato de A. bisporus revelou duas bandas principais de ligação com IgE, de aproximadamente 10kDa e 27kDa. ( O teste de  27kDa.   .(-)Na literatura, há poucos casos de alergia alimentar a cogumelos, os quais são relatados principalmente na China, onde os cogumelos fazem parte da dieta. O último relato conhecido foi publicado em 2013.A. bisporus num paciente com asma e rinite. Trata-se de um caso incomum, que destaca a importância de estarmos alertas para alérgenos alimentares incomuns.Relatamos aqui um caso de anafilaxia por alergia a A. alternata , que apresentou episódio de anafilaxia induzida por exercício após ingestão de A. bisporus ; Dauby et al. descreveram uma paciente do sexo feminino com rinite alérgica e alergia a Hormodendrum cladosporioides , A. alternata , Fusarium vasinfectum , Helminthosporium interseminatum e Epicoccum nigrum , com síndrome alérgica oral a A. bisporus cru – em ambos os relatos de caso, os autores associaram a reação de hiperssensibilidade à reatividade cruzada entre alérgenos de bolores e cogumelos.De acordo com testes cutâneos e dosagens séricas, o paciente era alérgico a ácaros e cogumelos. Os testes cutâneos foram negativos para fungos e para todos os outros alérgenos alimentares considerados suspeitos. Sem sensibilização a fungos, esse paciente provavelmente apresentava sensibilização primária a cogumelos por ingestão e não reatividade cruzada com esporos de bolores ou outros fungos. Os casos relatados na literatura associam alergia alimentar a cogumelos com reatividade cruzada: Carrapatoso et al. descreveram o caso de um jovem do sexo masculino com rinite alérgica desencadeada por Fungi , como um dos possíveis alérgenos do A. bisporus numa paciente do sexo feminino, com episódios de anafilaxia após ingestão de A. bisporus e romã.Dauby et al. identificaram proteínas termolábeis de A. bisporus com peso molecular de 43kDa a 67kDa, com suposta reatividade cruzada com aeroalérgenos de fungos e relacionadas a um caso semelhante a uma síndrome alérgica oral.Duas proteínas IgE-reativas termoestáveis de aproximadamente 10kDa e 26kDa foram detectadas, embora a classe das proteínas não tenha sido estabelecida, e esses dois alérgenos fossem desconhecidos até a data do nosso relato de caso. Em outros relatos de casos, alérgenos de cogumelos diferentes foram identificados. Hegde et al. identificaram o manitol, principal componente carboidrato dos Após o diagnóstico de alergia a cogumelos, o paciente foi instruído a eliminar da dieta cogumelos e produtos que os continham. Foi prescrito um autoinjetor de adrenalina  para ser usado, se necessário.A. bisporus . O primeiro episódio descrito pelo paciente atende aos critérios clínicos de anafilaxia, uma apresentação bastante incomum. O teste de immunoblotting revelou duas proteínas IgE-reativas, de aproximadamente 10kDa e 27kDa.Há poucos casos descritos de alergia alimentar a cogumelos, e a maioria é explicada pela reatividade cruzada entre fungos e alérgenos alimentares. Os dados escassos relativos à sensibilização primária a cogumelos comestíveis e à alergia alimentar dificultam nossa abordagem diagnóstica, mas tornam nossos resultados ainda mais importantes, já que nosso paciente apresenta provável sensibilização primária a Apesar da contraindicação do teste de provocação oral, os resultados dos outros testes e a história clínica foram essenciais para que se estabelecesse o diagnóstico. A importância de se considerarem fontes alergénicas menos comuns como possíveis responsáveis traz desafios, mas é essencialmente relevante no campo das alergias alimentares.


To evaluate the effectiveness of adherence to a multidisciplinary renal health program in reducing mortality and progression to hemodialysis. We used a database that included patient monitoring (2013-2017), dialysis admissions and all cause of mortality in Peru. Adherence to the program was established by meeting minimum visits during the first year of monitoring. The outcome of interest was hemodialysis admissions or all cause-mortality. Kaplan-Meier curves, Log-Rank test and competing survival analysis methods were used to estimate the differential risk between adherent and non-adherent patients. A total of 20,354 participants was evaluated; 54.1% were male, 72.1 years old in average, 2.2 years average follow-up, and 15,279 (75.1%) belonged to the early stages (1 to 3a) of Chronic Kidney Disease. Adherence decreased the risk of renal replacement therapy in 41.0%  in the low-risk group and mortality in the high-risk group was 31.0% . The multidisciplinary care strategy with standardized assessments by stage is effective in reducing admission to .0when the patient is identified in early stages and in reducing mortality in advanced stages. However, in Lima, the country’s capital and where a third of the population resides, it has been estimated at 20.7%2. Kidney disease is the sixth leading cause of death in the country, with a 28.0% increase in the last 10 years. The cities that show the greatest growth in the proportion of deaths from CKD are those located in the Sierra region, among the most important reasons are the limited number of nephrologists3, and the subsequent delay in receiving care from a specialist4.The overall prevalence of chronic kidney disease (CKD) for all life stages has been estimated at between 11.0 and 13.0%. The prevalence of CKD in Peru is 13.2%5. Although this is lower than the average in Latin America (660 pmi)6. The total of 50.0% of patients with end-stage CKD do not have access to RRT. The Peruvian Ministry of Health recognized that demand has far exceeded national supply5.The natural progression of CKD leads patients in its final stages to the use of renal replacement therapy (RRT). The number of patients on peritoneal dialysis or hemodialysis is 415 patients per million in habitants (pmi) in Peru7.The economic impact of CKD is global, reaching all countries, regardless of the level of development and health model. While the annual spending on RRT can reach 100,000 USD, the investment in preventive measures to slow the CKD averages 10,000 USD. Hence the importance of primary and secondary prevention of CKD as a health care policy8. Additionally, undergoing RRT has a significant negative impact on the quality of life of patients. Reducing the number of new patients requiring RRT is a highly desirable scenario at the individual and social levels.Only 30% of Peruvians have social security, and it is in this health system where dialysis generates a significant financial burden. In 2017, expenditure on dialysis exceeded 1.2 million soles , equivalent to 6% of the institutional budget9.CKD management strategies are required to delay progression to dialysis or death. According to evidence, the most successful interventions include multidisciplinary care, control of the underlying disease and drug treatment to control modifiable risk factors. Follow-up and adherence are the key aspects for its success10.Non-adherence to chronic drug therapy significantly increases the disease burden. Factors associated with poor adherence include: drugs’ cost, treatment complexity and adverse effects, inadequate monitoring, weak patient-physician relationships and barriers to accessing health care facilities, which are more common in developing economies11. Embedded in this context and considering the recommendations of the WHO, the Renal Health Unit of the E. Rebagliati National Hospital, from Peru’s Social Security – EsSalud began the implementation of a secondary prevention plan in 2013. This intervention focuses on multidisciplinary management  of patients with risk factors for CKD such as diabetes, hypertension and age over 55, with the aim of reducing the progression of CKD, controlling underlying diseases and reducing overall mortality12. The aim of this study was to evaluate the effectiveness of adherence to a renal health program (RHP) in reducing mortality and progression to hemodialysis.The World Health Organization (WHO) promotes tactics aimed at timely management of disease and associated comorbidities, such as diabetes and high blood pressure (HBP)Analysis of monitoring data from a cohort of patients enrolled in the renal health program (RHP) of the E. Rebagliati Hospital and its healthcare network that includes primary care facilities, Lima-Peru, from January 1, 2013 to December 31, 2017. The monitoring ended on July 31, 2018.Three data bases were used: 1) Follow-up of the patients included in the RHP between 2013 and 2017; 2) Admissions to hemodialysis in the Rebagliati Network, which included starting dates of treatment; and 3) Overall mortality, constructed from the data (until July 2018) of the national registry of identification and civil status of Peru. The three files were provided with a unique alphanumeric code of identification (CI) for each patient, ensuring the anonymity of the information. With these three databases, a unique CI was designed including 23,144 subjects. We excluded data from subjects without a CKD diagnosis , in stage 5 CKD (n = 393), because they were already receiving dialysis treatment, under 18 years old (n = 19), outside the filtering period (n = 5), inconsistent data (n = 125), missing data (without CKD stage = 424 and date of death = 542).13. Risk factors included hypertension, diabetes mellitus and others .The exposure variable showed adherence to the RHP. An adherence threshold based on compliance with visits during the first year of admission was established by experts from the Renal Health Unit consultation: for patients with stage 1 and 2 CKD = minimum one visit, for stage 3a and 3b CKD = minimum two visits and for stage 4 CKD = minimum three visits. The stages of CKD were categorized according to their risk of progression  as CKD with low risk of progression: Stage 1 , Stage 2 (eGFR 90 < TFGe < 60 ml/ min and ACR > 30mg/g), and Stage 3a (60 < eGFR < 45 ml/min and ACR < 300mg/g); and CKD with high risk of progression: Stage 3a (60 < eGFR < 45 ml/min and ACR > 300mg/g), Stage 3b (45 < eGFR < 30ml/min), and Stage 4 (15 < eGFR < 30ml/min), according to KDIGO guidelinesThe outcome of the analysis was defined by time to hemodialysis or death . The effectiveness of adherence to the program was measured in terms of the presence of these outcomes.14. The “Cause-specific competing-risk survival analysis” package RStudio was used for the estimation15. Cox regressions were used for proportional Hazards in the case of death as an event. In both cases, Hazard ratios (instantaneous risk) were obtained, with a 95% confidence level and p < 0.05. The analyses were performed using the statistical package RStudio 3.5.016.For the survival analysis, Kaplan-Meier curves were used and a difference in distribution test (Log-Rank test) was applied to determine whether the curves were statistically different from each other. Survival models were used to evaluate the association between RHP adherence and the presence of hemodialysis or death. This association was crudely estimated and adjusted for the covariates identified as potential confounders of the main association . In the case of progression to hemodialysis, a competitive risk survival analysis was performed by calculating, from parametric regression, specific cumulative incidence curves for each riskThis study was approved by the Research and Institutional Ethics Committee of the Edgardo Rebagliati Martins Hospital.The total of 20,354 participants were evaluated. Of these, 54.3% were male and had an average age of 72.9 years [standard deviation (SD) = 12.6], mostly with stage 3a CKD (41.4%) and with high blood pressure as the most frequent risk factor (38.7%). The average monitoring time was 2.2 years (SD = 1.4), with 1.7% cases of hemodialysis starting and 10.9% deaths because of all causes during the monitoring period. Of the total population evaluated, 23.6% met the criteria to be considered adherent to the renal health program and 75.1% were identified in the low-progression risk group .The Kaplan-Meier curves for both groups with the beginning of dialysis as the event of interest showed a proportion of people not on dialysis exceeding 95% at the end of five years of monitoring . These pIn the Kaplan-Meier overall mortality curves for both groups, the group that did not adhere to the RHP had a lower survival than the adhered group throughout the study period . At the To evaluate the effect of adherence to the RHP on the start of hemodialysis, crude and adjusted regression analyses were performed, showing a change in the directionality of the association. Hence the stage of CKD would be an effect modifier on this association (data not shown). Thus, the results indicated that adherence to the RHP had differentiated effects for hemodialysis initiation depending on the stage of CKD. Adherence to the RHP, above and beyond age, gender and risk factors, decreased in 41.0% the probability of initiation of hemodialysis in patients with low risk of progression stages (CKD 1-3a). Age behaved as an independent risk factor in the high-risk stages, tripling even the probability of starting hemodialysis in the most gerontological patients. The mere fact of being male was a protective factor in all stages of CKD, decreasing by 49.0% (in high-risk stages) and 41.0% (in low-risk stages) the probability of starting hemodialysis. Adherence to the RHP reduced in 13.0% the probability of dying independently of the other variables evaluated. Age increased the risk of mortality by almost five times in older ages. High-risk stages had more than twice the probability of dying than low-risk stages, and men had 42.0% more risk than women (data not shown). However, when assessing adherence behavior in each of the CKD strata, it has a significant effect only on the high-risk group, decreasing the probability of dying by 31.0% regardless of age, gender, and risk factors . The ris9. Additionally, there is limited evidence that multidisciplinary models of care that provide care with a structured protocol have the potential to improve adherence and treatment goals.This study describes the effectiveness of a secondary prevention strategy developed with basis on clinical guidelines, executed by a multidisciplinary team, with the participation of primary care and nephrology professionals to reduce mortality and progression to hemodialysis. Adherence to the guidelines changes the possibility of admission to dialysis in patients at low risk of progression, and significantly reduces all cause-mortality in patients at high risk of progression. Despite the increasing prevalence of CKD, there is little published evidence about the effectiveness of different models of care in improving outcomes in clinical practice17 found that the probability of death was 145 times greater than the need for admission to RRT in patients over 80 years, due to the prevalence of multiple comorbidities, especially cardiovascular disease. Likewise, Soucie et al.18 state that age over 75 years is independently associated with a five-fold increase in the risk of death within 90 days after starting dialysis19. This early mortality is associated with predialysis health conditions. However, Hallan et al.20, in the meta-analysis to assess the possible interaction of age with clinical risk, conclude that low eGFR and high albuminuria are independently associated with mortality and dialysis admission.Age is an independent risk factor, directly associated with higher risk of dialysis initiation in the high-risk CKD group. Tonelli et al.21 associated timely referral to the nephrologist with a 58.0% decrease in mortality in the first 90 days of dialysis initiation in elderly patients with chronic end-stage renal disease. Our findings showed that older patients are more likely to dialysis initiating, especially in high-risk CKD patients, in contrast to the findings of Tonelli et al.17 Similarly, Lundstrom et al.22 showed that the 5-year probability of admission to RRT is lower among patients over 75 years old due to the competitive risk with mortality.The clinical risk parameters become essential in the evaluation and allow an early referral decision to the specialist. Baek SH et al.23 reported high rates of progression and initiation of RRT in males, suggesting that there is a biological component involved. While, Go et al.24, in assessing the risk of rapid progression for CKD among more than 36,000 American patients, found no significant difference for men and women. We propose that in addition to biological variables, cultural and social variables may be involved. In our environment, male patients are cared for by their families (daughters and wives), who ensure that they adhere to their treatment and diet.Male gender becomes a protective factor in all stages of CKD, decreasing the probability of dialysis admission by almost half in this study. However, Marks et al.25 In addition, the Korean national P4P , implemented with a multidisciplinary team care model, significantly improved the quality of CKD management, and reduced the risk of early mortality and health care expenses.26 Finally, Strand et al.27, in their systematic review in 2012, established that multidisciplinary care is effective in delaying the progression of CKD in adults, especially in the advanced stages. Education becomes an important component of care by increasing knowledge and understanding of the causes of CKD. Our work emphasizes the importance of teamwork to achieve specific goals, which would be achieved even in patients in advanced stages of CKD.The effectiveness of a secondary prevention strategy, using a multidisciplinary team, had already been observed in the economic evaluation of CanPREVENT . It concludes that the use of a team  in the consultation uses fewer resources and leads to lower health care costs without reducing the quality of life for patients with CKD.10. However, a study of CKD patients in the Netherlands showed that adherence to treatment reached 54.0%, but decreased as the stage of disease was more severe28. In our case, it may be due to problems in the health system, lack of appointments, bureaucracy, but may also reflect under-registration in the computer application, or the fact that we established a minimum number of evaluations per year according to stage to consider adherence.The adherence to the RHP was 23.6%. This is a low percentage in relation to the average number of patients adhering to a treatment scheme for chronic diseases, which can reach 74.0% in diabetic patients29 reported that low-risk CKD patients who adhere to RHP are less likely to begin dialysis. In addition, they conclude that low eGFR and high albuminuria should be considered at least as relevant a risk factor for CKD progression to dialysis in diabetics or hypertensive patients. Likewise, in clinical evaluation, models combining albuminuria and eGFR should be considered since they add significant predictive information on the risk of admission to RRT or death compared to models containing only one of the parameters in an isolated form30.Our study showed that adherence is strongly influenced by the stage of disease. Two meta-analyses2. Despite this, the country still has an incipient renal prevention program, having achieved partial development in social security assistance by the National Renal Health Plan approved in 2008, whose objectives are: to decrease the incidence of CKD in the population at risk, to organize health care, to strengthen the capacity of primary care resolution and to establish a surveillance system for renal health. This work describes the first experience in secondary prevention by levels of care, with computerized registration in this health system.The silent progression of CKD, its association with cardiovascular disease and the high cost of treatment make this disease a major public health concern, especially since kidney replacement therapy is out of financial reach for most Peruvians under their current health systemA limitation of our study is that only data from recording information from patients in monitoring and not clinical records were used. An immediate effect is the difficulty in managing the databases because they come from different sources, and the consequent greater probability of finding missing values in some variables. However, given the sample size after methodological exclusions , the proportion of missing values (4.7%) does not represent a serious threat to the validity of the results. On the other hand, there is less flexibility to model the categorization of variables, since the criteria that define them come from the very design of the records. An example is the category “others” in the risk factors including people aged over 55. Although age is a variable in itself, it is not possible to exclude those over 55 and put them in a new category, since it is impossible to differentiate patients whose risk factor is only their age from those with more than one reason for being in “others” category. We also use an expert opinion definition of adherence to establish the study groups. Although this is a valid method, because we are identifying the intervention group retrospectively, and based on a rule that is closely related to the patient’s inclination to participate in the intervention, there is a probability of selection bias that could lead us to overestimate the effect of the intervention. In addition, our study cohort only measured adherence in the first year, due to the difficulty in establishing criteria over time, since CKD is a dynamic disease, in which each patient can be stable, in progress or in remission. The average monitoring time of two years makes it difficult to assess survival because it is a relatively short period, so the findings should be interpreted with caution.Adherence to the renal health program has differentiated effects for hemodialysis initiating depending on the stage of CKD. It is effective in reducing the initiation of renal replacement therapy when patients are identified in early stages and has a significant effect on mortality in the group at high risk of progression, regardless of other factors such as age or gender. 1. Sin embargo, en la capital, Lima, donde vive un tercio de la población, se ha estimado en 20,7%2. La enfermedad renal es la sexta causa de muerte en el país, con aumento de un 28,0% en los últimos 10 años. Las ciudades que muestran mayor crecimiento en la proporción de muertes por ERC están ubicadas en la región de la sierra, donde hay pocos nefrólogos3, condicionando una referencia tardía al especialista4.La prevalencia global de enfermedad renal crónica (ERC) para todas las etapas de la vida se ha estimado entre, 11,0 y 13,0%. La prevalencia de ERC en el Perú es del 13,2%5, proporción baja en comparación a la media para Latinoamérica (660 pmh)6. Es decir, tenemos 50,0% de pacientes con ERC en estadio final que no accede a TRR en relación a otros países de la región. Más aún, el Ministerio de Salud reconoce que la demanda ha superado ampliamente la oferta nacional5.La progresión natural de la ERC lleva a los pacientes en sus estadios finales al uso de terapia de reemplazo renal (TRR). La cantidad de pacientes en diálisis peritoneal o hemodiálisis es de 415 pacientes por millón de habitantes (pmh) en el Perú7.El impacto económico de la ERC es global, llega a todos los países, independientemente del nivel de desarrollo y el modelo de sanidad. El promedio de gasto por año en TRR puede llegar a 100 mil dólares, mientras que la inversión en cuidados para enlentecer la ERC llega a 10 mil dólares en promedio. Por ello, estudios advierten de la importancia de la prevención primaria y secundaria de la ERC como política de asistencia sanitaria8. Adicionalmente, someterse a TRR tiene un impacto negativo importante en la calidad de vida de los pacientes. Reducir el número de pacientes nuevos que requieran TRR es un escenario muy deseable a nivel individual y social.El 30% de los peruanos cuenta con seguridad social, y es en este sistema sanitario donde la diálisis genera una importante carga financiera. En el 2017, el gasto en diálisis superó los 1,2 millones de soles, es decir, el 6% del presupuesto institucional9.Se requieren estrategias de cuidado de la ERC para retardar su evolución a diálisis o muerte. Las más exitosas incluyen programas con cuidado multidisciplinario, con control de la enfermedad de fondo y tratamiento farmacológico para el control de los factores de riesgo modificables. El tiempo de seguimiento y la adherencia al programa son los aspectos que pueden hacer la diferencia10.La falta de adherencia a la terapia farmacológica crónica aumenta significativamente la carga de enfermedad. Hay factores asociados a esta pobre adherencia como el costo, la complejidad y efectos adversos de la medicación; el seguimiento inadecuado, la relación deficiente entre el paciente y el médico, y las barreras para acceder a los centros de salud, circunstancias más frecuentes en las economías en desarrollo11. Inmerso en este contexto nacional y considerando las recomendaciones de la OMS, la Unidad de Salud Renal del Hospital Nacional Edgardo Rebagliati, de la Seguridad Social de Perú , comenzó la implementación de un plan de prevención secundaria en 2013. Esta intervención se centra en un manejo multidisciplinario de pacientes con factores de riesgo para la ERC como diabetes, hipertensión y edad mayor de 55 años, con la finalidad de reducir la progresión de ERC, controlar las enfermedades de fondo y reducir la mortalidad general12. El objetivo de este estudio fue evaluar la efectividad de la adherencia a un programa de salud renal (PSR) en la reducción de mortalidad y progresión a hemodiálisis.La Organización Mundial de la Salud (OMS) promueve tácticas que apuntan a un manejo oportuno de la enfermedad y comorbilidades asociadas, como la diabetes y la hipertensión arterial (HTA)Análisis de los datos de seguimiento de una cohorte de pacientes conformada por aquellos que ingresaron al programa de salud renal de la Red Sanitaria Rebagliati, Lima-Perú, desde el 01 de enero del 2013 hasta el 31 de diciembre del 2017. El seguimiento finalizó el 31 de julio del 2018.Fueron utilizadas tres bases de datos: 1) De seguimiento de los pacientes incluidos en la PSR de la Red sanitaria Rebagliati entre 2013 y 2017, 2) De hemodiálisis de la Red Sanitaria Rebagliati, de donde fueron extraídas las fechas de inicio de hemodiálisis de los pacientes incluidos y 3) De mortalidad, construida a partir de los datos (hasta julio del 2018) del registro nacional de identificación y estado civil del Perú. Los tres archivos fueron proporcionados con un código alfanumérico de identificación único (CI) para cada paciente que garantizó el anonimato de la información. Con estas tres bases de datos, se diseñó una única identificada por el CI que incluía 23.144 sujetos. Se excluyeron datos de sujetos que no calificaban como ERC (n = 1.429), ERC estadio 5 (n = 393), menores de 18 años (n = 19), fuera del periodo de tamizaje (n = 5), datos inconsistentes (n = 125), datos faltantes .13. Los factores de riesgo incluyeron hipertensión, diabetes mellitus y otros .La variable de exposición estuvo determinada por la adherencia al programa de salud renal con cuidado multidisciplinario . Ésta se estableció por recomendación de expertos de la Unidad de Salud Renal y consenso de los investigadores a partir del cumplimiento de visitas durante su primer año de ingreso: para los pacientes con ERC estadio 1 y 2 = mínimo una visita, para ERC estadio 3a y 3b = mínimo dos visitas y para ERC estadio 4 = mínimo tres visitas. Los estadios de ERC fueron categorizados en función a su riesgo de progresión  como ERC con bajo riesgo de progresión: Estadio 1  > 30mg/g], Estadio 2 (90 < TFGe < 60 ml/min y RAC > 30mg/g), y Estadio 3a (60 < TFGe < 45 ml/min y ACR < 300mg/g); y ERC con alto riesgo de progresión: Estadio 3a (60 < TFGe < 45 ml/min y ACR > 300mg/g), Estadio 3b (45 < TFGe < 30ml/min), y Estadio 4 (15 < TFGe < 30ml/min), de acuerdo con la guía KDIGOEl desenlace del análisis estuvo definido por tiempo a evento hemodiálisis o muerte . La efectividad de la adherencia al programa se midió en términos de la presencia de estos desenlaces.14. Se utilizó el paquete “Cause-specific competing-risk survival analysis” de R estudio para la estimación15. Fueron utilizadas regresiones de Cox para Hazards proporcionales en el caso de la muerte como evento. En ambos casos, se obtuvieron ratios de Hazard (riesgo instantáneo), con un nivel del 95% de confianza y p < 0,05. Los análisis se realizaron utilizando el paquete estadístico R estudio 3.5.016.Para el análisis de supervivencia se utilizaron curvas de Kaplan-Meier y se aplicó un test de diferencias en la distribución (Log-Rank test) para determinar si las curvas fueron estadísticamente diferentes entre sí. Se utilizaron modelos de supervivencia para evaluar la asociación entre la adherencia al PSR y presentar hemodiálisis o morir. Esta asociación fue estimada de manera cruda y ajustada por las covariables identificadas como potenciales factores de confusión en la asociación principal . En el caso de la progresión a hemodiálisis, se realizó un análisis de supervivencia por riesgo competitivo, mediante el cálculo, a partir de una regresión paramétrica, de curvas de incidencia acumuladas específicas para cada riesgoEste estudio fue aprobado por el Comité de Investigación y Ética Institucional del Hospital Edgardo Rebagliati Martins.Se evaluaron 20.354 participantes. De estos, el 54,3% fueron varones y tuvieron una edad promedio de 72,9 años [desviación estándar ], mayoritariamente con ERC en estadio 3a  y con hipertensión arterial como el factor de riesgo  más frecuente. El tiempo promedio de seguimiento fue de 2,2 años , presentándose 1,7% casos de debut en hemodiálisis y 10,9% muertes por todas las causas durante el periodo de seguimiento. Del total de la población evaluada, 23,6% cumplieron con criterios para considerarse adherentes al programa de salud renal y 75,1% fueron identificados en el grupo de bajo riesgo de progresión .Las curvas de Kaplan-Meier para ambos grupos con el inicio de diálisis como el evento de interés mostraron una proporción de personas sin diálisis superior al 95% al final de los cinco años de seguimiento . Estas pEn las curvas de mortalidad global de Kaplan-Meier para ambos grupos, el grupo no adherido al PSR tuvo una menor supervivencia que el grupo adherido en todo el período de estudio . Al finaPara evaluar el efecto de la adherencia al PSR en el debut a hemodiálisis, se realizaron análisis de regresión crudos y ajustados, evidenciando un cambio en la direccionalidad de la asociación. Se identificó que el estadio de la ERC estaría modificando el efecto en esta asociación (datos no mostrados). Así, los resultados indicaron que la adherencia al PSR tuvo efectos diferenciados para el debut a hemodiálisis dependiendo del estadio de la ERC. De tal forma, la adherencia al PSR, independientemente de la edad, sexo y factores de riesgo, disminuyó en un 41,0% la probabilidad de debutar a hemodiálisis en los pacientes con estadios de bajo riesgo de progresión (ERC 1-3a). La edad se comportó como un factor de riesgo independiente en los estadios de alto riesgo, triplicando incluso la probabilidad de debutar en hemodiálisis en los pacientes más gerontes. El solo hecho de ser varón fue un factor protector en todos los estadios de la ERC, disminuyendo en 49,0%  y en 41,0% (en estadios de bajo riesgo) la probabilidad de debutar a hemodiálisis .La adherencia al PSR disminuyó en un 13,0% la probabilidad de morir independientemente de las demás variables evaluadas. La edad incrementó el riesgo de mortalidad en casi cinco veces en las edades más avanzadas. Los estadios de alto riesgo tuvieron más del doble de probabilidad de morir respecto a los de bajo riesgo y los hombres tuvieron 42,0% más riesgo que las mujeres (datos no mostrados). Sin embargo, al evaluar el comportamiento de la adherencia en cada uno de los estratos de ERC, tiene un efecto significativo sólo en el grupo de alto riesgo, disminuyendo en un 31,0% la probabilidad de morir independientemente de la edad, el sexo y los factores de riesgo . Los est9. Adicionalmente, hay evidencia limitada que los modelos de cuidado multidisciplinario que brindan atención con un protocolo estructurado pueden mejorar la adherencia y los objetivos del tratamiento.Este estudio describe la efectividad de un programa de salud renal organizado con base en guías clínicas, el cuidado por un equipo multidisciplinario, y establecido por niveles de atención con la participación de profesionales de atención primaria y de nefrología en términos de reducción de mortalidad y de progresión a hemodiálisis. La adherencia al mismo modifica la posibilidad de ingresar a diálisis en los pacientes de bajo riesgo de progresión, y disminuye significativamente la mortalidad por todas las causas en los pacientes con alto riesgo de progresión. A pesar del incremento de la prevalencia de la ERC, hay poca evidencia publicada sobre la efectividad de los diferentes modelos de cuidado en mejorar los resultados en la práctica clínica17 encontraron que la probabilidad de muerte era 145 veces mayor que la necesidad de ingreso a TRR en pacientes mayores de 80 años, debido a la prevalencia de múltiples comorbilidades, sobre todo, enfermedad cardiovascular. Así mismo, Soucie y col.18 afirman que la edad mayor de 75 años se asocia de forma independiente con un incremento de cinco veces el riesgo de muerte dentro de los 90 días posteriores al inicio de la diálisis19. Esta mortalidad temprana está asociada a condiciones de salud previas al inicio de diálisis. Sin embargo, Hallan y col.20, en el metanálisis para evaluar la posible interacción de la edad con el riesgo clínico, concluyen que la TFGe baja y la albuminuria elevada se asocian de forma independiente con la mortalidad y el ingreso a diálisis.La edad se comporta como un factor de riesgo independiente, evidenciando que a mayor edad mayor riesgo de mortalidad y mayor riesgo de debutar en diálisis; en el grupo con ERC de alto riesgo. Tonelli y col.21 asociaron la referencia oportuna al nefrólogo con una disminución de 58,0% en la mortalidad en los primeros 90 días de inicio de diálisis en pacientes ancianos con enfermedad renal crónica terminal. Nuestros hallazgos evidenciaron que a mayor edad los pacientes tienen mayor probabilidad de debutar en diálisis sobre todo en los pacientes con ERC de alto riesgo, en contraposición a los hallazgos de Tonelli et al.17 Del mismo modo, Lundstrom et al.22 evidenciaron que la probabilidad a cinco años de ingreso a TRR es más baja entre los pacientes mayores de 75 años debido al riesgo competitivo con mortalidad.Los parámetros clínicos de riesgo se vuelven imprescindibles en la evaluación y permiten una decisión de referencia temprana al especialista. Baek SH y col.23 reportaron altas tasas de progresión e inicio de TRR en varones, sugiriendo que hay un componente biológico involucrado. Mientras que, Go et al.24, al evaluar el riesgo de rápida progresión para ERC entre más de 36.000 pacientes estadounidenses, no encontraron diferencia significativa para varones y mujeres. Planteamos que pueden intervenir más que variables biológicas, variables culturales y sociales. En nuestro medio, los pacientes varones son cuidados por sus familiares (hijas y esposas), quienes se encargan de que cumplan su tratamiento y su dieta.El sexo masculino se convierte en un factor protector en todos los estadios de ERC, disminuyendo en casi la mitad la probabilidad de ingreso a diálisis en este estudio. Sin embargo, Marks et al.25. Así mismo, el programa P4P (programa de pre diálisis) nacional coreano, implementado con un modelo de atención en equipo multidisciplinario, mejoró significativamente la calidad del manejo de ERC, y redujo el riesgo de mortalidad temprana y los gastos de atención de la salud.26 Finalmente, Strand et al.27, en su revisión sistemática en el 2012, establecieron que la atención multidisciplinaria es eficaz para retrasar la progresión de la ERC en adultos, especialmente en los estadios avanzados. La educación se convierte en un componente importante de la atención logrando aumentar el conocimiento y la comprensión de las causas de la ERC. Nuestro trabajo incide en la importancia de trabajar en equipo para lograr objetivos específicos, que se conseguirían incluso en los pacientes con estadios avanzados.La prevención secundaria, utilizando un equipo multidisciplinario, ya había sido apoyada por la evaluación económica del CanPREVENT . Se concluye que el uso de un equipo  en la consulta utiliza menos recursos y conlleva menor costo para el cuidado de la salud sin reducir la calidad de vida para pacientes con ERC10. No obstante, un trabajo realizado en pacientes con ERC en Holanda mostró que la adherencia terapéutica llegaba al 54,0%, pero disminuía conforme el estadio de enfermedad era más severo28. En nuestro caso, esto puede deberse a problemas propios del sistema de salud, falta de citas, burocracia, pero también puede reflejar subregistro en el aplicativo informático, o el hecho de que establecimos un número de evaluaciones mínimas por año según estadio para considerar adherencia.La adherencia al programa de salud renal fue de 23,6%. Esta es una cifra baja en relación al promedio de adherencia a un esquema de tratamiento en enfermedades crónicas, que puede llegar a un 74,0% en pacientes diabéticos29 reportaron que los pacientes con ERC de bajo riesgo que se adhieren al PSR tienen menor probabilidad de debutar en diálisis. Adicionalmente, concluyen que la TFGe baja y la albuminuria elevada se deben considerar al menos como un factor de riesgo igualmente relevante para la evolución a ERC en diálisis en personas diabéticas o hipertensas. Así mismo, en la evaluación clínica, se debe considerar modelos que combinen albuminuria y TFGe pues agregan información predictiva significativa sobre el riesgo de ingreso a TRR o muerte en comparación con los modelos que solo contienen uno de los parámetros en forma aislada30.Nuestro estudio evidenció que la adherencia está fuertemente influenciada por el estadio de enfermedad. Dos metanálisis2. A pesar de ello, el país aún tiene un programa de prevención renal incipiente, habiendo logrado un desarrollo parcial en la seguridad social a través del Plan Nacional de Salud Renal aprobado en 2008, cuyos objetivos son: disminuir la incidencia de la ERC en la población de riesgo, organizar la atención de salud, fortalecer la capacidad de resolución de atención primaria y establecer un sistema de vigilancia para la salud renal. Este trabajo describe la primera experiencia en prevención secundaria por niveles de atención, con registro informático en este sistema de salud.La progresión silenciosa de la ERC, su asociación con enfermedad cardiovascular y el costo elevado del tratamiento hacen que esta enfermedad sea de gran preocupación para la salud pública, sobre todo, porque la terapia de reemplazo renal está fuera del alcance financiero para la mayoría de peruanos bajo su actual sistema de saludUna limitación de nuestro estudio es que solo se utilizaron los datos de registro de información de pacientes en seguimiento y no registros clínicos. Un efecto inmediato es la dificultad en el manejo de las bases de datos por provenir de diversas fuentes, y la consecuente mayor probabilidad de encontrar valores perdidos en algunas variables. No obstante, dado el tamaño de muestra luego de exclusiones metodológicas (n = 20.354), la proporción de valores perdidos  no representa una amenaza seria a la validez de los resultados. Por otro lado, se tiene menos flexibilidad para modelar la categorización de las variables, puesto que los criterios que las definen provienen del diseño mismo de los registros. Un ejemplo es la categoría “otros” en los factores de riesgo que incluye personas mayores de 55 años. Aunque la edad es una variable en sí misma, no es posible excluir a los mayores de 55 y ponerlos en una nueva categoría, ya que es imposible diferenciar los pacientes cuyo factor de riesgo es únicamente su edad, de aquellos con más de una razón para estar en “otros”. Asimismo, usamos una definición de adherencia con base en la opinión de expertos para establecer los grupos de estudio. Aunque este es un método válido, debido a que estamos identificando retrospectivamente el grupo de intervención, y basándonos en una regla muy relacionada con la disposición del paciente a participar en la intervención, existe una probabilidad de sesgo de selección que podría llevarnos a sobreestimar el efecto de la intervención. Además, nuestra cohorte de estudio solo midió la adherencia en el primer año, debido a la dificultad para establecer los criterios en el tiempo, ya que la ERC es una enfermedad dinámica, donde cada paciente puede mantenerse estable, progresar o remitir. El tiempo de seguimiento promedio de dos años dificulta valorar la supervivencia por ser un periodo relativamente corto, por lo cual los hallazgos deben ser interpretados con cautela.La adherencia al programa de salud renal tiene efectos diferenciados para el debut en hemodiálisis dependiendo del estadio de la ERC. Es efectiva en reducir el inicio de terapia de reemplazo renal cuando se identifican pacientes en estadios tempranos y tiene un efecto significativo sobre la mortalidad en el grupo de alto riesgo de progresión, independientemente de otros factores como la edad o el género.