Epidemiology and Social Issues of ESKD in Easter Island
Rapa Nui, or Easter Island, is a remote volcanic island 3800 km west of Chile with a population of 8445. Owing to its isolation, until recently, patients with ESKD had to relocate to mainland Chile for KRT, isolating them from family support. Previous experience with peritoneal dialysis (PD), initiated and trained on the mainland, resulted in poor outcomes and discouraged further local adoption. Contributing factors included poor patient adherence, suboptimal hygienic conditions, some mechanical complications, and frequent peritonitis, leading to inadequate treatment outcomes and unacceptably high mortality rates. As a result, hemodialysis became the preferred modality for KRT, while PD remains available but with limited uptake. Kidney transplantation is limited due to a shortage of living donors, cultural barriers, and extended waiting times for deceased donors. Transplantation requires patients to travel to mainland Chile for the procedure and follow-up, further complicating care. The dialysis unit is dedicated to chronic adult dialysis and cannot accommodate pediatric patients or care for AKI.
Expanding Dialysis Services in a Remote Territory: Medical Organization and Telemonitoring Support for Enhanced Care
Rapa Nui island adheres to Chile's health care regulations, with kidney disease management and treatment covered under the country's Explicit Health Guarantees.1 Despite funding from Fondo Nacional de Salud and Instituciones de Salud Previsional, its remote location limits care. Recognizing the urgent need to care for patients with ESKD despite the challenges of a remote location, limited medical resources, and previous negative experiences with PD, local authorities, led by the mayor, fought to establish a dialysis facility offering continuous, lifesaving treatment, through an innovative hybrid model. This approach combines telemedicine, connecting the local team with a remote nephrologist, and on-site care provided by a highly trained nurses, technicians, and a physician.
The local dialysis team received specialized and comprehensive training at a referral hospital in mainland Santiago and receives ongoing medical education. Hemodialysis is provided in two shifts, 6 days a week. Nurses monitor patients, with a general physician supervising daily operations. A mainland Chile nephrologist offers 24/7 remote support, visits every 5–6 weeks, and periodically reviews patient's electronic medical records (EMRs). Monthly laboratory tests and assessments are performed and documented in the EMR.
Emergent patients are stabilized locally and then airlifted to mainland Chile for advanced care in referent hospital. The dialysis center works in close collaboration with the local and mainland hospitals, ensuring the availability of essential emergency supplies and maintaining continuity of care.
Treatment Modality—Clinical Practices and Patient Management
The Rapa Nui unit provides chronic hemodialysis treatment for 17 stable patients with ESKD, including nine permanent residents and eight transient patients.
Hemodialysis is initiated at a mainland facility before transferring the patient back to Easter Island. All vascular access procedures are performed at the referral mainland hospital in Santiago. Patients undergo thrice weekly hemodialysis sessions lasting 4 hours using high-flux hemodialyzers. Postdilution high-volume hemodiafiltration (HDF) is the preferred modality. Vascular access consists of arteriovenous fistulas in 44% of patients, arteriovenous grafts in 33%, and tunneled central venous catheters in 22%. Anticoagulation is achieved with unfractionated heparin. Erythropoietin and iron are used to manage anemia. Phosphate binders, such as vitamin D3 supplements, antihypertensives, and diabetes medications, are prescribed as needed. Patient monitoring and kidney replacement targets follow Chilean best practice guidelines.2
Social Effect and Patient Outcomes
Since the Rapa Nui Dialysis Unit opened in April 2023, 17 patients with ESKD have received treatment locally. This has allowed most patients previously treated on the mainland to return to the island, reducing their time away from family and easing the treatment burden on both patients and their families. None have returned to work. On average, patients spent 42 months on the mainland for dialysis (interquartile range, 13–111 months) before being transferred to Rapa Nui for care.
Over the past 18 months, there have been seven hospitalizations (median length, 9.5 days) in mainland Chile for vascular access complications,1 acute coronary syndrome (3), pneumonia (1), prostate cancer (1), and heart failure (1). Five patients died (at a median age of 67 years) from sudden cardiac death, myocardial infarction, extreme cachexia, prostate cancer, and septic shock. None of the deaths were directly related to dialysis complications.
Technical Details of Dialysis
Infrastructure, Materials, and Care Organization of the Hemodialysis Facility
The Rapa Nui Hemodialysis Center, 150 meters from Hanga Roa Hospital, is a two-story facility with four dialysis beds. The first floor houses a waiting area, dressing room, hemodialysis room, meeting room, bathrooms, and water treatment system. The second floor contains storage and sanitary rooms. It has four reclinable chairs (three operational and one backup) and a central nurse monitoring unit. It features handwashing sinks, emergency medication storage, oxygen supply, and air conditioning.
The online HDF equipment consists of four machines (5008s Cordiax, Fresenius Medical Care [FMC]) equipped with high-flux polysulfone dialyzers (FxCorAL 600 & 800, FMC, Bad Homburg, G). Ultrapure dialysis fluid is ensured by two Fresenius ultrafilter device which are replaced periodically. Sterile substitution fluid produced online is also used for priming, rinsing, and intravenous boluses, effectively suppressing the need for commercially prepared sterile bag solutions. Machines are disinfected after each treatment through thermal and chemical methods per manufacturer instructions. Dialysis fluid is prepared using liquid acid concentrates and sodium bicarbonate (Bibag, 650 g).
The local care team provides hemodialysis in two shifts, 6 days a week. Nurses monitor patients, with a general physician supervising daily. A mainland nephrologist offers 24/7 remote support, visits every 5–6 weeks, and reviews the EMR periodically. Monthly laboratory results and assessments are captured in the EMR. In emergencies, patients are stabilized locally and airlifted to mainland Chile. The center collaborates with Hanga Roa Hospital and mainland hospitals, maintaining necessary emergency supplies.
Water Provision and Water Treatment System
Drinkable tap water for the hospital is supplied by the municipality and managed by Sociedad Agrícola y Servicios Isla de Pascua (SASIPA) Sociedad por Acciones (Chilean legal entity type), which extracts water from six deep wells in Hanga Roa. The untreated water is stored in six ponds, undergoes disinfection, and is distributed through a 73 km network of pipes. The Superintendency of Sanitary Services of Chile ensures SASIPA complies with drinking water quality regulations, ensuring safe water for the population. The water treatment system includes a 1200 L storage tank to ensure supply during occasional shutdowns. Pretreatment includes a sand filter, two alternating water softeners, and an activated carbon filter. Ultrapure water is produced through one reverse osmosis module, microfiltration, and ultraviolet radiation (Aqua water treatment unit 250, FMC, bad Homburg, G) and circulated to the dialysis unit through a pump-assisted loop.
Power Electricity Supply
The dialysis unit's energy is supplied by Hanga Roa Hospital through SASIPA, which operates a power plant next to Mataveri Airport. The plant uses seven generators with a total capacity of 8050 kW and 400 solar panels generating up to 128 kWh, averaging 750 kWh daily (about 22,000 kWh monthly). The hospital is also equipped with an auxiliary power circuit and backup generators to ensure uninterrupted care during occasional power outages.
Staffing and Nursing
The staffing and nursing team consists of a medical director specialized in nephrology acting remotely by telemedicine, a full-time resident doctor on duty (with dialysis and emergency training), two nurses with dialysis training ensuring care and coordination, two dialysis technicians to ensure maintenance of water treatment and hemodialysis machines, a care assistant, and a medical secretary assistant.
Pharmaceutical Provision, Disposable Supply, and Preparedness for Natural Disasters
The Rapa Nui Hemodialysis Center follows a strict single-use policy for all disposable materials. Dialyzers, needles, tubing, and electrolyte containers are discarded per local health care waste protocols (Residuos de Establecimientos de Atención de Salud [Health Care Waste]) and sent to Hanga Roa Hospital for transport to mainland Chile for incineration. Disposable dialysis materials and medications are supplied by Hanga Roa Hospital's pharmacy, which receives shipments from mainland Chile every 3 months by 1-week sea transit. The Rapa Nui Hemodialysis Center is stocked with sufficient disposable materials and medications to ensure uninterrupted treatment for all patients for up to 3 months at a time.
To address potential natural disasters, such as earthquakes or tornadoes of medium intensity, the infrastructure of the Rapa Nui Hemodialysis Center has been designed and reinforced for resilience. Critical systems, including water supply and power generation, have been fortified to ensure uninterrupted operations in emergency situations.
Health Care Reimbursement Policy and Tariff
KRT on Rapa Nui follows Chilean health care policy, with nationwide reimbursement system funded by the National Health Fund (Fondo Nacional de Salud). The local dialysis unit receives about $75 per dialysis session, which covers medications and laboratory tests, and is currently sufficient to support HDF cost. However, no additional funding is provided for advanced treatments such as HDF, meaning patients face no out-of-pocket costs, despite the significant logistical and operational challenges of the island's remote location. Emergency procedures, complications, or hospitalizations are reimbursed separately from the standard hemodialysis tariff, including costs for sanitary air transport to mainland Chile if needed.
Conclusions
The dialysis unit on Rapa Nui marks a significant advancement for patients with CKD in this remote region. Its success is due to the dedication of the Rapa Nui Dirección de Desarrollo Comunitario and local and national health care teams, who have trained a full medical, nursing, and technician staff. The initiative also benefits from reliable water treatment, high-quality dialysis machines, and telemedicine support, improving the quality of life for patients. Ongoing government support, along with improvements in logistics and staffing, is crucial for sustaining and expanding this service. The unit will soon open positions for holiday patients from mainland Chile or abroad.
Supplementary Material
Acknowledgments
The authors thank Pedro Edmunds Paoa, Mayor of Rapa Nui, along with Graciela Rubiño, and Cecilia Araki, dedicated nurses at the Rapa Nui Dialysis Unit, and Dr. Vanessa Molina whose support made this project possible. The content of this article reflects the personal experience and views of the authors and should not be considered medical advice or recommendation. The content does not reflect the views or opinions of the American Society of Nephrology (ASN) or Kidney360. Responsibility for the information and views expressed herein lies entirely with the authors.
Disclosures
Disclosure forms, as provided by each author, are available with the online version of the article at http://links.lww.com/KN9/B59.
Funding
None.
Author Contributions
Conceptualization: Bernard Canaud, René Clavero.
Data curation: René Clavero, Carlos Schlack.
Supervision: René Clavero.
Validation: Bernard Canaud, René Clavero.
Visualization: Bernard Canaud, René Clavero.
Writing – original draft: Bernard Canaud, René Clavero.
Writing – review & editing: Bernard Canaud, René Clavero, Carlos Schlack.
References
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