Through several questions, based on easily verifiable data, the author decided to contextualize the doubts currently existing in the field of nephrology in Portugal.

The graphs that accompany the questions show the existing data that support them. However, the questions remain unanswered, and at the moment, the only answer to all the questions asked would be "we don't know".

The lack of explanation that justifies the questions makes it impossible to introduce appropriate and effective clinical measures to change the current paradigm: extremely high levels of incidence and prevalence in dialysis, with an enormous impact on the national health budget.

Keywords: hemodialyse, peritoneal dialyses, incidence, prevalence, comprehensive price

Portugal is a country with a recognized high level of clinical activity in nephrology and with a number of public and private units for dialysis treatment and kidney transplantation, per million inhabitants, among the highest in Europe.¹

There is a National Health Service open to the entire population and all expenses with dialysis treatments - hemo and peritoneal - and kidney transplantation, are fully supported by the national health budget.

Peritoneal dialysis and kidney transplantation are performed exclusively in the public sector. Chronic hemodialysis treatment is performed in both, predominantly in private units (90%), the most part belonging to large international companies (43% Nephrocare, 30% Diaverum, 10% Davita,4% B Braun and 13% others).

The national health budget (NHB) predominantly contemplates the treatment of the diseases and is very scarce with regard to prevention. The percentage of NHB for prevention is lower than the average found in other European countries.

All patients with stage 5 chronic kidney disease are observed in nephrology hospital departments in the state public sector and, when it is decided to place the patient on a renal replacement therapy and there is no capacity to do so, they are sent to private satellite units. Criteria for admission to renal replacement treatment are not uniform and are subject to personal views, moral and ethical issues.²

Since 2008, the Ministry of Health has created an online platform (MHOP)³ where, before starting the chronic dialysis program, the patient's demographic, clinical and laboratory data must be registered. This platform has always been under the responsibility and supervision of the National Health Board (NHB) and the Nacional Commission for Monitoring of Dialysis (NCMD) and any possibility has been allowed for the data to be known either by doctors, by the general population or by the patients themselves.

There is no explanation for this situation. Therefore, various hypotheses arise, such as the lack of much data, frequent errors, lack of transparency or something more complex that NHB considers not to be made public. For example, Edgar and collaborators refer in their article² that in the MHOP, "the online registry designed to enable a detailed record of all movements of patients starting dialysis, such as hospital admissions, changing between modalities... " "only 5 patients were recorded as changing to peritoneal dialysis after hemodialysis (January 2010-December 2016).’’ In the Portuguese Society of Nephrology Society Dialysis Registry (PSNR),⁴ this transition is mentioned to have occurred in a much higher number: four hundred and fifty eight(458 pts) patients transitioned, during that period, from one modality to the other, value that in current practice is known to be certainly the correct.

This almost total lack of information means that, even for many of the physicians who have been working in nephrology for many years, they continue to have, in certain areas, such as dialysis, many unanswered questions.

Some of these questions are too important to be forgotten.

1. Why is the incidence of patients in dialysis in Portugal almost double that of Spain who have very similar risk levels for chronic kidney disease and its progression? (Figure 1)¹
2. Why is there such a huge difference in the incidence of dialysis between Portugal and the neighboring Autonomous Regions of Spain (Galicia, Castilla et Leon, Estremadura and Andalusia? (Figure 2)¹
3. Why the incidence in dialysis in the Lisbon and Tagus Valley Region is two to three times higher than in other regions of the country? (Figure 3)^2,5
4. Why is the incidence of diabetic patients in dialysis in Portugal two, three and four times higher than in Spain, Sweden and Norway, respectively? (Figure 4)⁶
5. Why is the prevalence of dialysis in Portugal the highest in Europe? (Figure 5)⁶
6. Why is the prevalence of dialysis in Portugal twice that of the Autonomous Regions of Spain neighboring Portugal (Galicia, Castilla et León, Estremadura and Andalusia? (Figure 6)^1,6
7. How and on what basis was the comprehensive price of dialysis calculated? (Figure 7)^3,7
8. How was it possible to lower the value of the comprehensive price of dialysis treatment more than sixteen percent (around forty-five million euros/year) three years after it was implemented? (Figure 8)⁷
9. How is it possible to have fixed the same comprehensive price for hemodialysis treatment in the public and private sectors?^1,3,7
10. Why don't we send our individual data to the ERA-EDTA Dialysis Registry?
11. Why are there so few published research works in Portugal on incidence and prevalence in dialysis?
12. Why, knowing the much higher incidence and prevalence in Portugal in relation to other countries, and certain regions of the country in relation to others, the responsible authorities have not yet decided, as has been done in other countries,⁸ to study the levels of renal function of patients before dialysis, obligatorily registered on the computer platform, in order to verify if there is, and with what frequency, an early initiation of patients on dialysis?
13. Why are the health authorities in Portugal not interested in these matters and do not allow others to analyse the data of the National Health System Individual Registry?

Figure 1 Incidence in dialysis (pmp) in Portugal and Spain.

Figure 2 Incidence in dialysis (pmp) in Portugal and neighboring Autonomous Regions of Spain.

Figure 3 Global and Regional Incidence in dialysis (pmp) in Portugal.

Figure 4 Diabetes: incidence in dialysis in European countries (pmp).

Figure 5 Prevalence in dialysis in European countries (pmp).

Figure 6 Prevalence in dialysis (pmp) in Portugal and neighboring Autonomous Regions of Spain.

Figure 7 Comprehensive price of dialysis ( hemo & peritoneal).

Figure 8 Comprehensive price reduction from Feb. 2008 to Aug. 2011 (euro- pr/wk).

The health authorities - National Commission for Monitoring of Dialysis and the National Health Board – have the data that would very likely allow us to obtain concrete answers to most of these questions. Possibly they would also make it possible to establish appropriate and effective measures to change this paradigm.

Since 2008, 14 years ago, it has become mandatory to register all patients on the platform.³ Only one clinical article² has been published taking those data into account: to study the crude survival of patients starting dialysis in Portugal. Nothing else was allowed. The problem of the extremely high incidence and prevalence of dialysis in the country does not seem to interest the responsible authorities. They have the data but are not at all concerned with these matters.

The normality with which national associations of doctors, of nurses and of chronic kidney and dialysis patients accept such a situation leaves me perplexed.

None.

Authors declare that there is no conflict of interest exists.

None.

1. Martins Prata M “Incidence in dialysis in Portugal and Spain”.
2. de Almeida EA, Raimundo M, Coelho A. Incidence, prevalence and crud survival of patients starting dialysis in portugal (2010-16): analysis of the national health system individual registry. Clin Kidney J. 2020;14(3):869–875.
3. Despacho nº4325/2008. Ministério da Saúde, Diário da República nº 35/2008,serie II de. 2008.
4. Portuguese society of nephrology 2019 registry of dialysis and transplantation. 2022.
5. Martins Prata M. Why the incidence in dialysis in the lisbon and tagus valley region (lvtr) is two to three times higher than in other regions of the country. Port J Nephrol Hypert. 2021;35(2):75–81.
6. ERA. EDTA Registry 2019 annual report.
7. Martins Prata M. Impact of the price of dialysis treatment and the prevalence in dialysis on the health budjet in Portugal. Port J Nephrol Hypert. 2022;36(3):165–169.
8. Finnish registry for kidney diseases dialysis report.