Epidemiology of 376,383 arteriovenous fistula creations for hemodialysis over 9 years within the Brazilian Unified Public Health System and the Private Healthcare SectorBackground: Chronic kidney disease represents a growing public health challenge worldwide, particularly in low- and middleincome countries. In Brazil, where most patients with end-stage renal disease depend on the public healthcare system for dialysis and transplantation, ensuring adequate vascular access — with arteriovenous fistula (AVF) being one of the available options — is critical to sustaining treatment. Despite its clinical relevance, comprehensive national data on vascular access patterns across both sectors have historically been limited.
Objective: This study aimed to examine trends in AVF creation for hemodialysis across Brazil from 2015 to 2023, assessing differences in frequency, geographic distribution, and sectoral disparities between the public and private healthcare sectors.
Methods: A retrospective population-based analysis was conducted using anonymized data from national administrative databases: DATASUS (public sector) and D-TISS (private sector). The majority of AVF creation procedures were included. Statistical analyses considered regional adjustments and were performed using SPSS v.20, with significance set at p < 0.001.
Results: Over the nine- year period, 376,383 AVF procedures were recorded, with 90.57% occurring in the public sector. While the absolute number of AVF creations increased, the ratio of AVFs per 1,000 dialysis patients showed a declining trend. Regional disparities were evident, with the Southeast and South regions presenting higher procedure rates compared to other areas. The private sector consistently reported lower creation rates.
Conclusion: Although, separately, dialysis and AVF rates have risen steadily in Brazil, the relative rate between them has shown a decreasing trend over the years. The predominance of AVF procedures in the public system is more pronounced.
Keywords:
Renal Replacement Therapy; Health Status Disparities; National Health Programs; Kidney Failure; Chronic; Longitudinal Studies
RESUMO
Introdução: A doença renal crônica representa um desafio crescente de saúde pública em todo o mundo, particularmente nos países de baixa e média renda. No Brasil, onde a maioria dos pacientes com doença renal em estágio terminal depende do sistema público de saúde para diálise e transplante, garantir acesso vascular adequado — sendo a fístula arteriovenosa (FAV) uma das opções disponíveis — é fundamental para a continuidade do tratamento. Apesar de sua relevância clínica, dados nacionais abrangentes sobre padrões de acesso vascular em ambos os setores têm sido historicamente limitados.
Objetivo: Este estudo teve como objetivo examinar as tendências na confecção de FAV para hemodiálise no Brasil, entre 2015 e 2023, avaliando diferenças em frequência, distribuição geográfica e disparidades setoriais entre o sistema público e o privado.
Metodologia: Foi realizada uma análise retrospectiva de base populacional utilizando dados anonimizados de bases administrativas nacionais: DATASUS (setor público) e D-TISS (setor privado). A maioria dos procedimentos de confecção de FAV foi incluída. As análises estatísticas consideraram ajustes regionais e foram realizadas com o SPSS v.20, com significância fixada em p < 0,001.
Resultados: Ao longo do período de nove anos, foram registrados 376.383 procedimentos de FAV, sendo 90,57% no setor público. Embora o número absoluto de confecções de FAV tenha aumentado, a razão de FAVs por 1.000 pacientes em diálise apresentou tendência de declínio. As disparidades regionais foram evidentes, com as regiões Sudeste e Sul apresentando taxas de procedimentos mais elevadas em comparação com outras áreas. O setor privado registrou consistentemente taxas de confecção mais baixas.
Conclusão: Embora, isoladamente, as taxas de diálise e de FAV tenham crescido continuamente no Brasil, a taxa relativa entre elas apresenta tendência de queda ao longo dos anos. A predominância dos procedimentos de FAV no sistema público é mais expressiva.
Descritores:
Terapia Renal Substitutiva; Disparidades no Estado de Saúde; Programas Nacionais de Saúde; Doença Renal em Estágio Terminal; Estudos Longitudinais
INTRODUCTION
Chronic Kidney Disease (CKD) is a significant global health concern, affecting approximately 10% to 13.4% of people worldwide1,2. CKD is defined by structural or functional abnormalities in the kidneys that last for more than three months. If left untreated, CKD can progress to end-stage renal disease (ESRD). At this point, patients may require renal replacement therapies such as hemodialysis (HD) or peritoneal dialysis and may also be eligible for kidney transplantation (KT)3.
In 2010, approximately 4.9 to 9.7 million people required kidney replacement therapy (KRT)4. This scenario is particularly common in low- and middle-income countries (LMICs), where many patients with end-stage CKD do not receive KRT5. In contrast, some countries, such as the United States, reported some of the highest rates of replacement therapy in the world; however, these rates have declined since 20174,6.
In 2023, Brazil reported a total of 157,357 dialysis patients. Of these, 96.2% received HD, while 3.8% underwent peritoneal dialysis5. From 2015 to 2023, a total of 46,272 kidney transplants were performed in the country, averaging 5,141 cases per year. The number of transplants ranged from a minimum of 4,395 to a maximum of 5,834 cases per year7.
To enable effective hemodialysis and improve patient survival, reliable vascular access is essential3. The two main options for chronic treatment are arteriovenous fistulas (AVFs) and tunneled cuffed central venous catheters (TC-CVADs)8. The selection of vascular access must be tailored to each patient. However, U.S. guidelines suggest that approximately 66% of patients undergoing maintenance hemodialysis should utilize AVFs9. In cases where urgent dialysis is necessary and an AVF cannot mature quickly enough, it is appropriate to use a tunneled central catheter or a short-term catheter. Plans should be in place to remove these catheters once the fistula becomes functional. According to the Kidney Disease Outcomes Quality Initiative (KDOQI), AVFs are the first option for long-term vascular access for hemodialysis.
TC-CVADs are commonly used for the immediate initiation of dialysis or while patients are awaiting transplantation10. Consequently, their use has become increasingly prevalent, often exceeding what is clinically appropriate. These catheters provide temporary access for patients who will eventually benefit from an AVF, either while waiting for the procedure or during the maturation process of the fistula. If possible, an AVF should be placed in a timely fashion, ideally weeks or even months before the initiation of hemodialysis. Unlike temporary venous catheters, an AVF guarantees the high blood flow required for effective hemodialysis and ensures an adequate dialysis dose. However, TC-CVADs carry the same costs associated with complications as all types of catheters11. Although the conversion to fistulas has been gradually increasing, it still lags behind the use of catheters, especially among older patients in the US10.
In Brazil, with a population of approximately 200 million people12, around 72% rely on the publicly funded Unified Health System (SUS). The remainder is mainly covered by employer-sponsored private insurance (about 23%), while a small minority (less than 5%) pays for healthcare services out of pocket13. A recent study conducted in 2024 among public healthcare users—representing nearly 140 million individuals— identified a gradual reduction in the use of AVFs, accompanied by a growing reliance on TC-CVADs14.
The public healthcare system in Brazil has established a digital platform that collects data on procedures performed in public hospitals across the country. Recently, the private healthcare sector has also begun making its data available to the public, adopting practices similar to those of the public sector. By aggregating data from both sectors, it has become possible to conduct a comprehensive nationwide assessment of health in Brazil. This task was previously challenging due to limited data availability, given the country’s vast size.
This study aimed to analyze national data from both the public and private healthcare systems in Brazil between 2015 and 2023 regarding AVFs for hemodialysis. The objectives were to assess AVF rates and differences across regions, age groups, and sexes within both the public and private healthcare sectors. To our knowledge, this is the first study to describe and analyze such an extensive dataset in a country of continental dimensions. The findings provide comparative evidence that can inform the development of management strategies for CVD tailored to the Brazilian context15.
National monitoring initiatives, such as dialysis censuses based on voluntary center participation, provide relevant insights into vascular access practices; however, these data are typically cross-sectional and may be affected by incomplete coverage and selection bias. Consequently, there is limited availability of nationwide data reflecting the actual volume of procedures performed over time. The use of administrative databases allows the analysis of reimbursed procedures at the population level, enabling a more consistent assessment of temporal trends and comparisons between the public and private healthcare sectors. This approach offers a more comprehensive perspective on vascular access provision in Brazil.
METHOD
This is a retrospective, longitudinal, and population-based study, involving 376,383 procedures of patients with ESRD who underwent AVF creation across Brazil from 2015 to 2023. It offers a comprehensive national perspective on vascular access for hemodialysis over nine years.
The research protocol was reviewed and approved by the institutional ethics committee under protocol number 4.321.508. Since all data were obtained from fully anonymized databases, the requirement for informed consent was waived, ensuring compliance with ethical standards while maintaining patient confidentiality.
The data were extracted from the TabNet platform of the Department of Information Technology of the Unified Health System (DATASUS) and from the private sector (D-TISS)16,17,18. DATASUS is a digital platform that collects data on procedures performed in public hospitals across Brazil. Registration in this database is required for a procedure to be eligible for payment. D-TISS is managed by a private system that provides access to procedure data. Overall population samples were derived from the Brazilian Institute of Geography and Statistics (IBGE)12 and the Brazilian Dialysis Census5,19,20,21,22,23,24,25,26, as well as from DATASUS and D-TISS16,17,18. This paper was structured according to the STROBE and RECORD statements27, both of which are checklists for data reporting.
This study analyzed procedures related to AVF creation within the public and private systems, encompassing most of the hemodialysis services across Brazil over 9 years. The unit of analysis was the number of procedures rather than individual patients. Due to the lack of patient-level identifiers, multiple procedures may have been performed in the same individual and analyzed as independent events. The extracted data included the prevalence by sex (biological assignment at birth), age, number of procedures performed in hospital and outpatient settings, and geographic region. The amount of dialysis per region was extracted from the Census (an estimated HD rate based on a sample from each region) and stratified by the regional population. For the overall analysis of the country, the total number of dialysis patients and the percentage corresponding to hemodialysis were extracted from the Census. In addition, using the percentage of HD financed by the public and the private systems, hemodialysis in each sector was estimated.
Procedure codes employed during selection and extraction from DATASUS for AVF creation are 0406020086 (for access), 0418010021 (with autologous graft), 0418010030 (for hemodialysis), and 0418010013 (with polytetrafluoroethylene [PTFE] graft). For D-TISS, the AVF creation codes are 30913144 (for hemodialysis) and 30908027 (with graft). Due to the administrative and reimbursement nature of the database, completeness of procedure-related variables is expected to be nearly complete. Missing data in demographic variables were handled as a separate category (“Not informed”, as presented in Table 1), without imputation.
Automated data retrieval was performed using Python (version 2.7.13; Beaverton, OR, USA) within a Windows 10 environment. Specific fields were identified, and tables were modified using Selenium WebDriver (version 3.1.8; SeleniumHQ) in conjunction with the Pandas library (version 2.7.13; Lambda Foundry, Inc., PyData). All information extracted was organized and compiled in Microsoft Office Excel 2016® (v. 16.0.4456.1003, Redmond, WA, USA).
We initially analyzed the estimated number of hemodialysis patients in both public and private services between 2015 and 2023. We also examined the estimated number of AVFs created in these services and the rate of AVF creation per thousand dialysis patients. In addition, we evaluated differences by age and sex, stratified by region, and overall AVF creation, also categorized by region.
Statistical analysis
The statistical evaluation was conducted with SPSS version 20.0 (IBM Corp., Armonk, NY). The evaluation of the relationship between procedure rates and region was performed using generalized linear models with a gamma distribution. For sex and age, generalized models with a Poisson distribution were used, incorporating the number of procedures as an offset. A p-value of less than 0.001 was regarded as statistically significant.
RESULTS
During the nine-year study period, a total of 376,383 AVF procedures were performed, along with 1,144,984 HD procedures. The creation of AVFs was more prevalent among males, revealing a significant difference in sex distribution between the public and private healthcare sectors (p < 0.001). In the public system, the rates were approximately ten times higher for both sexes compared to the private sector.
Additionally, there was statistical evidence indicating variations in fistula distribution by age group across these healthcare systems, as shown in Table 1. Younger individuals (aged 20–69 years) were more commonly found in the public healthcare system, while older age groups (70–79 and over 80 years) were more frequently seen in private facilities.
Most HD procedures were conducted within the public healthcare system, accounting for 80.68% of the total, as shown in Table 25,12,20,21,22,23,24,25,26. There was an increase in the demand for both public and private healthcare services. Notably, the HD rate per million inhabitants rose significantly, particularly in the private sector, which surpassed the public system in 2023.
The estimated number of AVF procedures performed in Brazil from 2015 to 2023, across both public and private healthcare services, is presented in Figure 1.
Our observations indicate that the public sector had AVF proportions nearly two to three times higher than those in the private sector. After adjusting the rates (first, for the ratio of hemodialysis to fistula) for better description, the rate in the public sector decreased from 40.6% in 2015 to a low of 33.5% in 2022, followed by a slight recovery in 2023. Conversely, in the private sector, the decline was more pronounced, dropping from 25.7% to 12.8% over the same period. In both cases, the results were more pronounced and significant in the public system.
The number of AVFs in the public sector was nearly ten times higher than in the private sector, with an average of 38,389 procedures (CI 2,661; 11,551) compared to 3,870 (CI 48; 202), respectively.
Table 3 presents the number of AVFs performed from 2015 to 2023, organized by region in Brazil and by type of service (public and private). In every region, the public sector consistently outperformed the private sector in terms of AVF procedures, with particularly significant differences in the North and Northeast regions.
The adjusted model, which accounts for geographic region, demonstrated an annual increase in procedure rates, with an estimated rate growth ranging from 0.4 to 7.9% per year. Over the nine-year period, the public healthcare system showed substantial and significant improvements across all regions, as illustrated in Table 3.
The rate of AVF creation per thousand dialysis patients in Brazil, stratified by region from 2015 to 2023, is shown in Figure 2.
Overall, there was either a reduction or fluctuation in rates across all regions over time, with an average annual decline of 1.6% (p = 0.01). Notably, the Northeast and North regions exhibited higher rates compared to the South and Southeast.
DISCUSSION
This study demonstrates that, although the absolute number of arteriovenous fistula creations has increased in Brazil, the proportion of definitive vascular access relative to the dialysis population is declining, with disparities between the public and private healthcare sectors. It analyzed a large sample of 376,383 procedures of ESRD patients who underwent AVF creation in Brazil between 2015 and 2023, covering both the public and private sectors. It represents the first and largest nationwide cohort of AVF creation for hemodialysis, with robust epidemiological relevance for assessing vascular access across the entire country. The use of national databases—DATASUS for the public sector and D-TISS for the private sector—was effective in capturing nearly all procedures (excluding those paid for out-of-pocket), as reporting is mandatory for billing purposes. The integration of population data from the Brazilian Institute of Geography and Statistics (IBGE) and the Brazilian Dialysis Census enhanced the analysis, enabling demographic stratification and calculation of standardized rates.
Over the nine-year period, 1,144,984 HD procedures and 376,383 AVF procedures were performed in Brazil, mostly in the public sector (80.68% and 90.57%, respectively), reaffirming its central role in ESRD care. While the number of HD patients remained steady until 2022, a modest decline in the public sector occurred in 20235, possibly linked to COVID- 19-related mortality28, whereas the private sector continued to rise, surpassing the public in the number of dialysis patients per million inhabitants.
The number of dialysis procedures increased from 2022 to 2023, accounting for over 92.97% of the total HD volume. Over the past nine years, the number of hemodialysis procedures totaled approximately 140,0005. Internationally, the United States recorded 639,883 new ESRD cases from 2015 to 2020, with a 3% decline in the use of AVFs29,30. In Brazil, the incidence of dialysis rose from 45,852 in 2019 to 51,153 in 20235,20. In contrast, the number of AVFs rose until 2019, dropped in 2020 due to COVID-1931, then rose again through 2023, though the AVF/HD ratio decreased, reflecting the increase in other approaches.
The data reveal significant differences between the public and private sectors in the use of AVFs for HD. The proportion of fistulas to hemodialysis in the public sector ranged from 33.5% to 40.6%, while in the private sector, it fell sharply from 25.7% to 12.8%. Despite adjustments for population size, rates in the public sector remained higher, though the gap narrowed. This disparity suggests that, while fistulas are widely recognized as the preferred treatment due to their ability to reduce the risks of infection, hospitalizations, and costs, the private sector is more dependent on catheters. This reliance may be attributed to factors such as patient clinical profiles, institutional preferences, or barriers to accessing vascular surgery9.
Although AVF creation increased overall, the percentage of AVFs relative to the total number of HD patients declined, particularly in the private sector, raising concerns about prolonged catheter use and its poorer outcomes. This trend is concerning from a clinical standpoint, as it suggests a longer duration of central venous catheter use, which is associated with poorer outcomes14. Similar trends occur in countries with aging dialysis populations and more comorbidities29,32, though international guidelines (KDOQI, ERA-EDTA) continue to recommend establishing definitive access whenever possible5,14,20,21,22,23,24,25,26. In contrast, Japan, Italy, and Germany report AVF rates above 60–70%, far higher than in Brazil, particularly in the private sector, underscoring room for improvement. Adapting initiatives like the Fistula First campaigns in the United States, tailored to fit the Brazilian context, could help increase the rate of access to definitive care.
During the study period, 376,383 AVFs were reported as newly established, though these numbers may not represent unique patients. A significant number of these entries did not include detailed classifications regarding the specific type of fistula created. Additionally, published evidence indicates substantial variability in AVF patency outcomes, which are often influenced by various clinical and demographic factors, such as patient age, comorbid conditions, and the anatomical type of fistula used33. In Brazil, two national studies have shown that over 50% of patients required the procedure more than once34,35. Due to the anonymous nature of the dataset, this study could not assess the individual frequency of procedures, the occurrence of complications, or the incidence of new hemodialysis cases in which most fistulas are expected to be created.
Regional analysis revealed that AVFs in the public sector significantly exceeded those in the private sector, particularly in the North and Northeast, where private involvement is relatively low compared to other regions. The Southeast had a higher absolute volume of procedures but one of the lowest AVF rates per thousand dialysis patients, indicating greater reliance on long-term catheters. Overall, AVF rates displayed declines or fluctuations across regions, with relatively higher rates in the Northeast and North and lower rates in the South and Southeast — patterns that likely reflect regional differences in health policy, infrastructure, and patient demographics. In 2020, a peak of 397 AVFs per thousand HD patients was observed in the North, possibly driven by specific initiatives, such as surgical campaigns or service reorganizations. At the same time, several regions saw declines, likely due to the suspension of elective procedures during the pandemic. Although the Southeast and Northeast had the highest absolute numbers of vascular surgeons in 2023, their surgeon-to-patient ratios were lower than in the South and Central-West due to significantly higher dialysis demand36. This imbalance may partly explain the lower AVF coverage in the Southeast, while in the Northeast, higher AVF rates may reflect regional prioritization or targeted interventions, despite the strain on surgical capacity.
AVFs were more frequent in men, with a statistically significant difference observed in both sectors (p < 0.001). In terms of age, younger patients (20–69 years) were predominantly treated in the public sector, whereas the private sector had a higher proportion of older patients (over 70 years). This age distribution may partly explain the lower AVF rates in the private sector, as older or comorbid patients are often less suitable for definitive vascular access.
Public healthcare performs far more HD and AVF procedures than the private sector, likely reflecting a higher prevalence of ESRD among its users, linked to poorer health conditions or limited access to healthcare. Additionally, many private patients seek these services in public facilities, a trend that has already been reported37,38.
In summary, although the public sector plays a dominant role and there has been overall growth in AVF creation in Brazil, the proportion of definitive access among HD patients is declining, particularly in the private sector, highlighting regional and sectoral disparities that underscore the need for targeted interventions to ensure equitable access to care.
Continuous monitoring and robust databases are crucial for evaluating the impact of policies and informing effective strategies. Advance vascular access planning in CKD is essential for increasing the proportion of patients who start and maintain HD with definitive access. The decline in the AVF/HD ratio emphasizes the importance of implementing measures such as early referral to vascular surgery, training multidisciplinary teams, establishing national monitoring of indicators, and adopting international benchmarks. Moreover, policies must address local demands, such as increasing the availability of vascular surgeons and specialized centers in underserved areas.
Limitations
The study does not permit causal inferences, thereby limiting its findings to associations and temporal trends. The lack of individual clinical data — such as comorbidities, disease stage, duration of dialysis, and reasons for choosing dialysis — further restricts the ability to account for specific risk factors and clinical contexts.
Reliance on secondary administrative databases may introduce inconsistent entries, while anonymization prevented patient-level longitudinal tracking, precluding the evaluation of outcomes and comorbidity profiles. It is important to note that the data reflect the number of fistula procedures performed, rather than the number of patients who underwent these interventions.
In the private sector, reliance on a single procedure code increases the risk of data overestimation and complicates the analysis. Moreover, individuals without private health insurance who pay out of pocket were not included in the private sector dataset, which may affect the generalizability of the results.
Another limitation is the absence of standardized procedural coding for catheter placement, particularly in the private healthcare sector, which prevented the inclusion of catheter-related interventions. Consequently, an essential component of HD practice could not be assessed, limiting a more comprehensive evaluation of access modalities within the population.
CONCLUSION
In Brazil, the number of dialysis and hemodialysis patients has risen over the nine-year study period. However, the ratio of AVFs to dialysis has decreased. A consistent pattern was observed: AVF procedures were more frequent in the public sector than in the private sector.
Acknowledgments
Not applicable.
Data Availability
All data from this study relied solely on publicly available and anonymized data obtained from the national databases. The databases analyzed in this study are available from the following sources: BrazilianInstitute of Geography and Statistics (https://www.ibge.gov.br/); Brazilian Dialysis Survey of 2009-2023; Data from the Private Healthcare System (https://app.powerbi.com/view?r=eyJrIjoiNzYwMTEy YjItZTE4OS00NTEzLTkxODctNTY5ZTVjZTI3MT llIiwidCI6IjlkYmE0ODBjLTRmYTctNDJmNC1iYmEzLT BmYjEzNzVmYmU1ZiJ9); Data from the Public Healthcare System (https://datasus.saude.gov.br/informacoes-de-saude-tabnet/). All links were available and accessible at the time of publication. Additional aggregatedanalyses can be provided upon reasonable request to the corresponding author.
Consent to participate
Ethical approval
Use of Artificial Intelligence Tools
Funding
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AVF: arteriovenous fistula; HD: hemodialysis.
AVF: arteriovenous fistula.