Kidney Supportive Care: Principles, Practice, and Pathways for Fiji

Introduction

Dialysis and kidney transplantation are life-extending treatments but are not universally accessible or appropriate; and many patients with advanced chronic kidney disease (CKD) experience distressing symptoms and diminished quality of life. Kidney supportive care (KSC), strongly supported by the ISN,¹ addresses these concerns by focusing on symptom relief, psychosocial support, and aligning care with patient values and goals.² It is a key element of kidney failure management (Figure 1) and is now a fundamental part of nephrology practice.³

Figure 1.

The “3 pillars” of kidney failure treatment options and the roles of kidney supportive care. CKM, conservative kidney management (without dialysis).

KSC is particularly relevant in resource-limited settings, where dialysis may be unavailable or unaffordable. Conservative kidney management (CKM) is a subset of KSC for patients with kidney failure who do not receive kidney replacement therapy.2, 3, 4 This is an active treatment pathway, but without dialysis, and it becomes a critical option⁴ for these patients to receive compassionate care without abandonment.

Principles of KSC

The ISN defines KSC as: “An approach that improves the quality of life for people with all stages of CKD, both those receiving and not receiving kidney replacement therapy, and their families, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems—physical, psychosocial, and spiritual.”²

KSC principles are described in detail in the ISN Academy.⁵ These include shared decision-making, through engaging patients and families in discussions about treatment options, prognosis, and goals of care; symptom management, by addressing symptoms such as fatigue, pruritus, pain, nausea, and restless legs; advance care planning, through facilitating conversations about future care preferences, including end-of-life decisions; continuity of care, by supporting patients throughout their kidney failure disease trajectory; and multidisciplinary collaboration, involving nephrologists, other physicians, primary care providers, nurses, palliative care specialists, dietitians, social workers, and psychologists, among others (Figure 2).

Figure 2.

Roles of nurses, doctors, and allied health staff in 1 kidney supportive care clinic. Other clinical models can be applied. EOL, end-of life.

The Need for KSC in Fiji

Global Burden of Disease data between 1990 and 2023 show an increase in age-standardized CKD prevalence by 5.4% and age-standardized rates of deaths by 62% in Fiji.⁶ Of adults 17% have diabetes, projected to increase.⁷ CKD is projected to be 4.6% of total disability-adjusted life years, with an annual increase of 1.8% by 2050.⁸ and diabetes is projected to be 20.6% of total disability-adjusted life years. CKD stage 5 incidence is 793 per million population, compared with 190 per million in Australia,⁹ and annual dialysis mortality is approximately 21%.¹⁰ Thus, Fiji faces a growing CKD crisis, driven largely by diabetes and hypertension.

Fiji has a predominantly public health system with 3 divisional hospitals (tertiary), 21 Subdivisional hospitals (secondary), 84 health centers (primary) and 99 nursing stations (primary). Referrals are needed from primary care to access specialist services, including nephrology. There is a growing private health care sector, and a public-private partnership with 1 divisional hospital.

Fiji has 3 nephrologists for a population of nearly 1 million. Currently, 310 patients access chronic hemodialysis at 9 centers in urban areas, with limited access for rural and maritime populations. Peritoneal dialysis is rarely used. Whereas dialysis is free at the public center and the public-private partnership center, costs range from $250 to $360 FJD per dialysis elsewhere. The government provides a subsidy of $180 per session if household income is < $30,000 FJD, resulting in a gap fee of $70 to $180 FJD per session paid by the patient. With 30% of the population living below a poverty line of $41.9 FJD weekly,¹¹ many are unable to afford dialysis 3 times/wk, or at all. Accordingly, many patients in Fiji pursue CKM because of the high cost of dialysis, geographical location, personal choice, or medical unsuitability. However, structured KSC is lacking and there is no established palliative care, that is, no specialized palliative care physician or palliative care nurse in Fiji. This high mortality and symptom burden, and moral distress of staff caring for these patients, highlight the urgent need for a KSC program in Fiji.

Cultural and Social Considerations for Providing CKM in Fiji

Fiji’s population consists of Indigenous Fijians (i-Taukei) and ethnic minorities, predominantly Fijians of Indian descent. Strong family and community ties play essential roles in decision-making and caregiving. Spiritual beliefs and traditional practices often influence how patients perceive illness, treatment, and end-of-life care. The experience of death and dying for an individual will impact the perception of illness for their family and their close-knit community.

As distinct from high-income countries, where patients opting for CKM are typically older with multimorbidity, younger individuals in Fiji may choose CKM because of geographical and financial constraints. These younger patients experience a high symptom burden while shouldering social responsibilities and caregiving roles, trying to balance employment, caring for dependents, and community responsibilities amid limited support systems. KSC and particularly CKM embedded in community and hospital settings is necessary to help these patients.

Communication about prognosis and treatment options must be tailored to health literacy disparities, often requiring translation into i-Taukei and Hindi languages. Involvement of community leaders such as Turaga-ni-koro and religious priests is necessary. The limited health care workforce in Fiji means that caring for CKM patients, including end-of-life, relies largely on families and informal caregivers within the local community, who are often distressed or overwhelmed and do not know what to expect. KSC in Fiji is urgently needed to provide support (practical and psychological) for these families and communities.

A Way Forward: Establishing KSC in Fiji

Implementing KSC in Fiji requires a phased, locally adapted approach, based on successful KSC programs such as in parts of the USA, UK, Canada, and Australia.^12,13 The multidisciplinary team roles in a typical KSC service are outlined in Figure 2, adaptable for Fiji’s needs and staffing.

Key lessons from well-functioning KSC teams globally include the following: integration of KSC within nephrology, primary care and general medicine services, rather than as a separate silo; multidisciplinary teamwork, involving doctors, nurses, dieticians, social workers, and spiritual leaders, adapted to Fiji’s limited workforce; community and patient engagement, where patients and families are active participants in decision-making; capacity building through the Nephrology Society of Fiji building partnerships with Australian and New Zealand Society of Nephrology, ISN, and the Asia-Pacific Society of Nephrology to develop local expertise while learning from international best practice.

Key elements of KSC that can be implemented immediately into existing clinics and dialysis reviews include symptom assessment using the i-POS Renal tool, and symptom management guided by online and direct ISN Academy teaching. Advanced care planning has cultural sensitivities and may be better referred to as planning for “my wishes,” integrated into regular clinical touchpoints.

The key emphasis is on nonabandonment, ensuring patients and families feel supported, even when other treatment options are no longer viable.

The following recommendations to help establish KSC emerged from the 2025 symposium hosted by the Nephrology Society of Fiji and the Internal Medicine Organisation of the Pacific on “Compassionate Care Across Pacific Cultures: A Holistic Approach to Palliative Care.”¹⁴

Phase 1: Foundation

The key elements are as follows (i) Document the need, by collecting data on symptom burden, quality of life, and advance care planning gaps. Fiji’s renal data infrastructure now includes a dialysis and transplant registry; a CKM registry is feasible to help understand the resource requirements and burden. (ii) Engage the willing by identifying motivated clinicians to begin KSC, even on a small scale. A fully funded program is not needed to start. (iii) Build a team by assembling a multidisciplinary group of clinicians already working with kidney failure patients, including nurses, nephrologists, and internists with interest in palliative care, members of the Internal Medicine Organisation of the Pacific, allied health professionals, and members of the Australian and New Zealand Society of Nephrology who can provide resources, education, and clinical support, in person and virtually.

Phase 2: Infrastructure

The key elements are as follows: (i) Create a dedicated space by establishing a visible, accessible clinic area within existing renal or general medicine services; (ii) Develop referral pathways by enabling nursing and doctor referrals from dialysis units, inpatient wards, and primary care; (iii) Start small and begin with a pilot program in 1 center, focusing on high-need patients.

Phase 3: Sustainability

The key elements are as follows: (i) Data collection: track performance measures such as symptom control, hospitalization rates, and patient and family satisfaction, using standardized forms; (ii) Education and training: conduct workshops, grand rounds, and bedside teaching about KSC, particularly CKM and symptom management; (iii) Build capacity firstly by engaging community service providers and educators regarding renal specific end-of-life care, then in the longer-term, by developing formalized KSC links among the Nephrology Society of Fiji and the Internal Medicine Organisation of the Pacific, primary care providers, and private sector nongovernment providers of dialysis. (iv) Seek funding. Once KSC has begun, even with a limited service, the data describing palliative needs and treatment outcomes can be used to apply for a formal national KSC program. Models for this exist in some other parts of the world, including Australia. (v) Advocacy and awareness, best achieved by presenting cases locally, nationally, and in the Pacific region, to promote KSC. (vi) Engage patient advocates to increase community engagement and address barriers.

Phase 4: Long-Term Vision

Cultural change takes time, and persistence and leadership are key to expanding KSC across the Pacific, beyond Fiji. As the program grows, with ISN support, it will meaningfully impact patients and caregivers, becoming a core part of CKD management in the region.

Conclusion

KSC represents an active, compassionate, evidence-based approach to managing CKD. It aligns medical care with patient values, improves symptom control, and reduces unnecessary hospitalizations. In Fiji, where CKD burden is high and dialysis access is limited, KSC, including CKM offers a practical and humane solution. With committed teams and strategic implementation, KSC can transform renal care and improve lives.

Even beginning with just 1 dedicated KSC service, adopting the principles outlined above, and supported initially by experienced KSC teams in other parts of the world, such a service will grow rapidly in Fiji. Indeed, the structured proposals provided above could form a template for KSC that can be nuanced for many other low-income countries throughout the world.