Kidney disease in Paraguay.

Paraguay is a landlocked country located in South America with a total population of 5,884,491. Most of the population (95%) is mestizo, a mixture of Spanish and American/Indian races. The total number of indigenous people in the country has increased from 38,703 in 1981 to 85,674 in 2002. The gross domestic product per capita was US $932.00 annually per person in the year 2002. Between 1992 and 1997, there were 380 patients on chronic dialysis in Paraguay and 75 patients received renal transplants, mostly living-related. The prevalence of renal replacement therapy was 87 patients per million, and the incidence of renal disease continues to rise. Seventy percent of cases of ESRD are of unknown etiology and 15% have diabetes-related renal disease. Only citizens covered by the employee's national health insurance have complete coverage for dialysis and transplantation. The remainder of the population has to apply to public hospitals when the need for hemodialysis arises. At such hospitals, they can receive hemodialysis coverage from the National Institute of Nephrology or from other medical foundations to obtain entrance to these programs. They must otherwise use their own resources to pay for treatment. Seventy percent of patients on chronic dialysis turn to public hospitals for treatment. Hospital hemodialysis is the method most widely used. Home dialysis is rarely performed and there are very few programs for ambulatory peritoneal dialysis. Thus, a large number of patients are not able to enter chronic dialysis programs. In a recent survey of 4655 ill children registered, the distribution of main renal disease was acute glomerulonephritis in 42 cases (9 per 1000), nephrotic syndrome in 40 cases (8.5 per 1000), systemic lupus erythematosis in 28 cases (6 per 1000), and hematuria alone in 11 cases (2.3 per 1000). In ambulatory pediatric practice, urinary tract infection is the leading reason for seeking medical advice. Two thirds of such cases are associated with urinary tract anomalies. Children with ESRD are able to enter hemodialysis programs, but there are not sufficient resources to transplant them. Over 60% of the children with ESRD are hospitalized with terminal renal failure; malformations of the urinary tract are the usual cause. One study of 9880 adults aged 18 to 74 years reported that 39.1% of the women and 26.8% of the men examined were found to have hypertension. Almost half who were found to have raised blood pressure in this study were not previously known to have hypertension. In another cross-sectional study of the urban and suburban mestizo population of Asuncion among patients between 20 and 74 years of age, the overall prevalence of diabetes mellitus was 6.5%, impaired glucose tolerance 13.5%, hypertension 17%, and obesity 31.6%. Extrapolating from this data, we can assume that 178,000 patients with hypertension in Paraguay need medical treatment. To face the problem of growing numbers of patients with end-stage renal failure, it is necessary to carry out basic epidemiologic research to detect and quantify cases early in the course of disease, and thus propose treatments designed to slow the progress of the disease. Without this type of data, it would be difficult to establish an efficient action plan for improving the development of the treatment of renal disease. Thus, we are recommending the establishment of early detection and treatment campaigns for chronic renal disease, especially in individuals at risk. It is also desirable to promote renal transplantation using related live donors. We need to cooperate with government authorities to increase the insurance coverage of patients on chronic dialysis and find the most practical ways to establish long-term dialysis programs. A major question that is hard to answer in practice is whether there should be universal insurance for dialysis and transplantation for all who need it from the outset, as opposed to implementation in successive stages, which gives priority to only a minority of the population; which could be better adapted to our financial possibilities.