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Background: The epidemic of non-communicable disease in the Compact nations of the US Affiliated Pacific Islands and the associated renal complications drive the demand for hemodialysis. Limited healthcare budgets and a lack of trained human health resources in these areas make hemodialysis a challenging undertaking that may require significant sacrifices in competing health care priorities. Methods: Two nephrologists who developed hemodialysis in the US Affiliated Pacific Islands provide its history. Cost estimates of hemodialysis for the Compact nations are collected from a 2014 hemodialysis feasibility report. The experiences and outcomes of current hemodialysis centers in the United States and other island nations provide a framework by which to assess the potential benefit and impact of hemodialysis in the Compact nations. Discussion: A consideration of how and why different stakeholders value hemodialysis will be crucial because they will drive the public's response to the institutionalization of any new intervention or the cessation of any existing intervention like hemodialysis. Conclusion: Updated cost estimates for dialysis clinics and data on renal disease rates in the Compact nations will be necessary to make informed decisions about hemodialysis in the current health systems. In the meantime, it is essential to enhance current medical interventions and public health strategies to prevent kidney disease and decrease the risks for kidney failure. Such preventive interventions must be culturally appropriate, effective, cost-efficient, and sustainable in the unique context of the Pacific., (©Copyright 2020 by University Health Partners of Hawai‘i (UHP Hawai‘i).)

A 9-year-old boy in Hawai'i presented with bleeding and thrombocytopenia and was subsequently found to have post-streptococcal glomerulonephritis. He recovered completely with intravenous immune globulin, antibiotics, short-term antihypertensive therapy, and supportive management. This case was similar to the 5 cases previously reported in the literature, with the exception that steroids were not used as the primary immune-modulating therapy.

Multiple doses of imipenem/cilastatin were administered to patients with end-stage renal disease undergoing long-term hemodialysis. Schedules of 250 mg every six hours, 500 mg every six hours, and 500 mg every 12 hours were studied. Five hundred mg every 12 hours was the most efficient schedule that maintained effective trough antibiotic activity. Twelve volunteers including two patients with clinical infections using the dose schedule of 500 mg every 12 hours received imipenem/cilastatin for two to 14 days without any notable clinical side effects. Imipenem peak and trough concentrations averaged 29 +/- 5 micrograms/ml and 10 +/- 3 micrograms/ml, respectively. No accumulation of imipenem occurred during the trial. Cilastatin peak and trough concentrations were 89 +/- 38 micrograms/ml and 70 +/- 27 micrograms/ml, respectively. The plasma concentration of cilastatin increased with each dose until the next hemodialysis session.

Thirty-five transplants have been performed in 29 children, 1 week to 16 years old. Of these patients 79 per cent are surviving from 9 months to 14 years post-transplantation. Eighteen of these patients have required different surgical procedures for transplantation than adult patients. Immunosuppressive therapy has been essentially the same as in adult patients. A striking difference between the living related donor and the cadaver donor transplant functional survival as seen in this series is unexplained at the present time. Linear growth has been good in those children who have required minimal doses of corticosteroids to maintain adequate renal function.

Thirty-one children received 38 kidney transplants from 22 live and 16 cadaver donors. Among the 31 patients, 25 received one transplant each, 5 received two transplants each and 1 received three transplants. Peritoneal or hemodialysis (or both) was carried out in 22 patients, with an average dialytic maintenance of 12 weeks before transplantation. Posttransplant immunosuppressive therapy included prednisone and azathioprine. Antilymphocyte globulin was administered to 33 recipients as adjunctive immunosuppressive therapy. At present, 23 patients have functioning allografts, 3 are on hemodialysis and 5 are dead. Of 22 live kidney transplants, 18 are presently functioning two months to 14 years after transplantation with an average of 36 months. Of 16 cadaver kidney transplants, 5 are presently functioning 9 to 57 months after transplantation with an average of 32 months. Actuarial live donor allograft survival for one year was 76 percent, for two years was 66 percent and for three years was 64 percent. Cadaver allograft survival was 50 percent, 40 percent and 40 percent, respectively. Complications were urologic and infection related. Of nine recipients with sustained hypertension, in six the condition was due to chronic rejection, while in one it was due to recurrence of the original disease in the allograft. Linear growth was measured in 15 children who were less than 14 years of age at the time of transplantation and in whom allografts survived more than one year. Maximum average linear growth velocity occurred during the first year after transplantation. Our experience indicates pediatric renal transplantation can be successfully used in the treatment of terminal renal failure.

The pharmacokinetics of ceforanide were evaluated in 11 patients with end stage renal disease (creatinine clearance less than 5 ml/min). A single intravenous dose of 750 mg/m2 produced peak plasma concentrations of 123 +/- 29 microgram/ml. The plasma half-life (T 1/2) of the drug was 19.1 +/- 2.5 h. A 5.5 h hemodialysis session removed 53% of the drug and reduced the T 1/2 to 5 +/- 0.7 h. Plasma concentrations greater than 10 microgram/m2 were maintained without adverse effects with a 1.5-g/m2 dose administered three times a week for 2 weeks.