The Progress of Nephrology in Pacific Island Countries of Oceania

Introduction

Kidney care in low- and middle-income settings has had significant challenges and advancements globally, and Oceania is no exception.¹ The region, comprising Australia, New Zealand, and a large group of Pacific Island countries (PICs), including Melanesia, Micronesia, and Polynesia, is affectionately termed the Blue Pacific Continent by its members and faces unique challenges and opportunities in the field of nephrology. With a diverse yet sparse population spread across a vast geographic area, the provision of nephrology services in this region must be both innovative and adaptable.

Middle-income PICs include Fiji, Kiribati, Marshall Islands, Federated States of Micronesia, Papua New Guinea, Samoa, Solomon Islands, Tonga, Tuvalu, and Vanuatu. The high income PICs include Nauru, Palau, the French territories of French Polynesia and New Caledonia; and the US territories of American Samoa, Guam, and Northern Mariana Islands (Figure 1).

Figure 1.

The Blue Pacific continent – the Pacific Island countries of Oceania.

The first ISN Saving Young Lives (SYL) workshop in Oceania was held in Nadi, Fiji in tandem with the Nephrology Society of Fiji’s Seventh Annual Symposium from July 31 to August 3, 2024. More than 100 participants from various disciplines from Fiji, Kiribati, Papua New Guinea, Solomon Islands, Samoa, Tonga, and Vanuatu participated. The meetings marked substantial progress in the recognition and management of kidney disease in Oceania in both adults and children.

This manuscript provides an overview of the progress in nephrology within Oceania, especially the middle-income PICs because of their shared resource limitations, focusing on chronic kidney disease (CKD), kidney replacement therapy (KRT), acute kidney injury (AKI) and the importance of societal support.

CKD

CKD is a major public health issue in Oceania, driven by rising rates of diabetes mellitus, hypertension, and obesity. The prevalence of CKD varies across the region, with higher rates observed in indigenous populations and those living in urban areas.

Data from the Global Burden of Disease database demonstrate the burden of CKD in Oceania. The estimated prevalence of CKD in the PICs ranged from 8.1% (95% confidence interval: 7.5%–8.8%) in Solomon Islands to 13.5% (95% confidence interval: 12.5%–14.7%) in Fiji.² Notably, Oceania had much higher age-standardized disability-adjusted life-years rates due to CKD than expected based on sociodemographic index for all years between 1990 and 2017, and the largest age-standardized rate of cardiovascular disease disability-adjusted life-years attributable to impaired kidney function compared to other regions.²

Given the high costs of KRT, improved screening of high-risk groups leading to early diagnosis is the most cost-effective strategy in resource-constrained PICs. However, this is undermined by poor access to essential diagnostics because of both government procurement inefficiencies and geographical isolation, with many communities living on remote islands where health care infrastructure is minimal or absent, making regular screening and follow-up care difficult. Point-of-care diagnostic tools are a potential way forward for this setting; however, thus far, cost is a major barrier to their use. In addition, the absence of electronic laboratory information systems across almost all PICs, including in large tertiary hospitals, severely hampers access to diagnostic results. Such systems are also necessary for the implementation of automated eGFR reporting, which has proven to be a key success in Fiji in changing the understanding of CKD in both the general and health care professional community. Addressing these basic barriers to timely diagnosis needs to be urgent priority on national noncommunicable disease policies.

Although foundational treatments such as angiotensin-converting enzyme inhibitors are universally available across PICs, significant knowledge gaps exist among health care professionals about their importance and use. In addition, despite the World Health Organization listing sodium-glucose cotransporter 2 inhibitors on the essential medicines list in 2021, almost all middle-income PICs lack access to them because of their high cost. The development and implementation of simple and locally adapted CKD guidelines for primary care, in addition to lobbying for government procurement of recently marketed generic sodium-glucose cotransporter 2 inhibitors are promising approaches to improve CKD management in the region.

KRT

In Oceania, access to and funding of chronic KRT varies widely, reflecting the region’s economic and health care disparities.¹ Samoa and Fiji have long-standing chronic hemodialysis programs, predominantly publicly funded,^3,4 whereas Papua New Guinea has had a privately funded program for a similar duration. Under increasing societal and political pressure to treat the rapidly growing burden of CKD, expanded access to chronic dialysis in the public health systems is in varying stages of planning and implementation in Kiribati, Solomon Islands, Tonga, and Vanuatu.

However, patient outcomes lag significantly behind the neighboring high-income countries in the region, with 1-year mortality on hemodialysis estimated at 21% in Fiji and reported as 33.5% in Samoa.⁴ KRT comes with the risk of substantial financial impact, as seen in Samoa, where approximately 6% of the national health budget is spent to provide in-center hemodialysis for < 200 people (< 0.1% population). PICs embarking on new dialysis centers must work carefully to ensure national KRT policies do not hamper other important health initiatives, including improvement of CKD management in primary care.

Despite potential effectiveness and cost advantages for kidney failure management, uptake of peritoneal dialysis remains very low in the Pacific. Frequently cited barriers include an inconsistent supply of prepackaged peritoneal dialysis therapy, transport costs, and clinical uncertainty due to potential high rates of infection. Although low-cost, portable technologies show potential, they remain a long way from impactful commercial viability.⁵

No middle-income PIC has established a kidney transplant program. Most patients with kidney transplants receive them overseas, predominantly in India because of the comparatively lower costs than in high-income regional neighbors. In the absence of registries, retrospective outcomes in Fiji appear reasonable with > 95% death-censored graft survival at 3 years posttransplant, although concerningly most recipients were male, infection was the dominant cause of death, and there is a risk of survival bias toward good outcomes. Papua New Guinea is pursuing establishment of an in-country, live-donor kidney transplant program despite formidable financial and technical barriers and the rest of Oceania is watching closely.

Registries and Research

Data-driven practice is gold standard but challenging in the Pacific. Data collection on outcomes has been difficult because of the time burden, lack of accessible medical records and laboratory data, and poor research infrastructure. Almost all centers still rely on paper records, difficult to access administrative datasets, and manual case record review for audit and research. Data for clinical governance, quality improvement, and research may be driven forward in the future through digital solutions, including electronic medical records.

Although most PICs have basic research structures in place, such as national ethics committees and academic institutions, there remains a need for greater local investment with protected research time for health professionals, strengthened governance and coordination of national research priorities, expanded funding mechanisms, and mentorship from international academic partners, with an emphasis on local leadership. In Fiji, the establishment of a REDCAP-based KRT registry, supported by The George Institute for Global Health, and maintained by local clinicians, is a major step forward for the Pacific region, and may be a template for other countries.³ Developing a minimum dataset across Pacific countries will advance knowledge of outcomes, drive advocacy efforts, and advance patient care.

AKI

In Oceania, the incidence of AKI has been reported as 21.4 and 26.8 per 1000 hospital admissions in Fiji and Samoa respectively, with sepsis and dehydration as the most common causes.^6,7 In-hospital mortality in these studies was high at 43% in Fiji and 20.2% in Samoa.

In many PICs, limited health care resources pose significant challenges in providing effective management of AKI. The lack of timely laboratory results, critical care facilities, and trained personnel often results in delayed diagnosis and suboptimal management. Indeed, of the 6 PICs represented at the SYL program in 2024, only 2 countries provide acute dialysis for children, and 4 countries provide it for adults. Although a substantial increase has been seen in the last decade, there remains only 4 nephrologists across multiple PICs. Therefore, there is a critical need to educate and train other practitioners, many of whom are delivering care for patients with AKI but have varying levels of understanding of AKI management principles and acute KRT.

To address these disparities, regional collaborations and training programs have been implemented. The SYL program, focuses on improving outcomes initially for young patients, but now also for adult patients with AKI in low-resource settings.⁸ By providing training for health care professionals, establishing local guidelines based on established international guidelines, and teaching the use of improvised techniques for peritoneal dialysis when essential equipment is unavailable, the SYL program hopes to make significant strides in reducing the burden of AKI in Oceania.

Importance of Societal Programs

Societal programs play a vital role in advancing nephrology in Oceania by providing opportunities for education and training, expertise-sharing and mentorship, and fostering partnerships between centers of excellence, and emerging renal centers to facilitate knowledge transfer and resource sharing.

The ISN Sister Renal Centre Program and the SYL program exemplify the impact of societal programs in Oceania. In 2015 the first ISN sister renal center partnership in the Pacific began between tertiary centers in Fiji and Australia. Over 6 years, Fiji experienced significant improvements in diagnostic services, workforce development, and specialty recognition, eventually becoming the first PIC with an established nephrology service. In 2024, the centers in Fiji and Australia incorporated a tertiary center in Papua New Guinea to form an ISN Trio, whereas a sister renal center partnership between centers in Samoa and New Zealand is now in its fourth year.

In 2024, recognizing the disparity in nephrology care between Australia and New Zealand and their neighboring PICs, the Australia and New Zealand Society of Nephrology established a Pacific Working Group to better coordinate their members’ engagement in the region, support local professional groups, provide research mentorship, advocate for the needs of the region, as well as develop an overarching roadmap for advancing nephrology in Oceania over the next 5 years.

By fostering international collaboration, these initiatives have built local capacity, improved access to care, supported research, and enhanced patient outcomes. Their success underscores the importance of continued investment in societal programs to advance nephrology in the region. The establishment of the first nephrology society in the Pacific in 2023, The Nephrology Society of Fiji, is an important milestone that can serve as a platform for providing such programs for Pacific people, by Pacific people.

Conclusion

Nephrology in the Oceania region has experienced notable progress, with specialist units and chronic KRT programs now established in several PICs. However, significant challenges remain, including limited resources, geographic barriers, and a shortage of renal-trained professionals relative to the disease burden in the region. Sustained progress will require culturally appropriate multidisciplinary training programs tailored to the region’s needs and suited to its resources. As emphasizing prevention and early detection is the key to curbing the alarming volume of kidney failure, strong advocacy from the nephrology community is essential to engage local Health Ministries in developing effective policies for acute kidney disease and CKD. The region’s remarkable resilience and adaptability, coupled with its strong regional collaboration through professional societies and international partnerships, offers a firm foundation. By leveraging these strengths and addressing the unique challenges of this diverse region, the outlook for nephrology in Oceania is one of growing promise and impact.