Renal Health Program: Improving Kidney Care for Aboriginal and Torres Strait Islander Communities

The Challenge

Chronic kidney disease (CKD) affects many Australians, but Aboriginal and Torres Strait Islander people, especially in remote areas, bear the greatest burden. CKD often occurs earlier, progresses faster, and leads to poorer outcomes. People are more likely to present late for dialysis, less likely to receive a transplant, and die younger than non-Indigenous Australians. Limited dialysis services in remote communities amplify the impact on families and communities.
CKD is closely linked to other chronic conditions such as diabetes and heart disease. To reduce this burden, we must understand what drives disease progression and identify acceptable, effective models of care.

Our Approach

The Renal Health Program within the Wellbeing and Preventable Chronic Diseases Division focuses on evidence translation and innovative strategies to improve service delivery and inform policy. We work in partnership with government and non-government health services to strengthen health systems and improve the patient journey.

• Knowledge translation – increasing the rate of implementation of research evidence
• Identifying evidence practice gaps so that they can be understood and addressed
• Digital health innovation through strong cross organisation partnerships and the ongoing development of Territory Kidney Care (TKC)
• Clinical research to ensure patient care is appropriate for the NT population
• Meaningful consumer engagement to support consumers role in research and service evaluation

Our multidisciplinary team includes researchers, statisticians, software developers, nurses, and First Nations consumer engagement officers.

Research Focus

• Discover better ways to diagnose, treat, and prevent chronic disease.
• Improve systems and processes to support patients across the care continuum.
• Translate research findings into policy and practice.

Impact

• Identified cost-effective, culturally acceptable CKD management strategies.
• Developed an innovative integrated clinical decision support system for chronic disease identification and management.
• Supported patient voice in care design, including determining value for money of service models, advocating for greater access to remote models and better understanding of health data usage.

Our Vision

Equitable access to kidney care for Aboriginal and Torres Strait Islander people—through systems that are responsive, culturally safe, and informed by lived experience.

Project partners

• Northern Territory Department of Health

Collaborators

• Ampilatwatja Health Care Aboriginal Corporation
• Aboriginal Medical Services Alliance Northern Territory
• Anyinginyi Health Aboriginal Corporation
• Australia and New Zealand Dialysis and Transplant Registry
• Central Australian Aboriginal Congress
• Central Australian Renal Voice
• Department of Corporate and Digital Development
• Katherine West Health Board
• Kidney Health Australia
• Laynhapuy Homelands Aboriginal Corporation Health
• Mala’la Health Service Aboriginal Corporation 
• Miwatj Health Aboriginal Corporation
• National Health and Medical Research Council
• Northern Territory Primary Health Network
• Northern Territory Renal Services 
• Pintupi Homelands Health Service
• Pandanus Medical GP Practice
• Purple House
• Red Lily
• Renal Advocacy Advisory Committee
• Sunrise Health Service
• Top End Medical GP Practice
• Transplant Society of Australia and New Zealand
• Wurli Wurlijang Health Service
• University of Melbourne
• University of Tasmania

Key staff:

• Professor Alan Cass
• Associate Professor Gillian Gorham
• Associate Professor Asanga Abeyaratne
• Associate Professor Oyelola Adegboye
• Dr James Harley
• Dr Sophie Pascoe
• Dr Winnie Chen
• Archana Shapkota
• Ben Creswick
• Harshana Munasinghe
• Henry Craigie
• Marylin Carino
• Natalie Merida
• Poonam Purohit
• Stephanie Long
• Trudi Sieland
• Victoria Thanasos
• Yomei Jones
• Kieran Bush

Honorary Researchers 

• Professor Paul Lawton
• Associate Professor William Majoni
• Paul Kamler (CNC)

PhD Researchers

• Ade Babatunde
• Dr Edith Waugh
• Mary Adewunmi
• Natalie Merida
• Dr Sajith Nayer
• Victoria Thanasos
• Vongayi Majoni

Current projects:

• The Big-RIVERS Project: Regional Integrated Vision for Effective Renal Support 2026
• CVD Check NT: Understanding and addressing cardiovascular disease (CVD) risk in a diabetes epidemic (commenced in 2025)
• Piloting the What Matters 2 Adults (WM2A) Wellbeing Measure Tool with Renal Patients in the Top End, Northern Territory (commenced in 2023)
• Renal Wellbeing Project (commenced in 2023)
• Supporting implementation of TKC in Aboriginal health services through locally based implementation officers (RART) (commenced in 2022)
• Territory Integrated Care: Primary health data Linkage Using Software (TIC PLUS) (commenced in 2021)
• Evaluation of impact of Territory Kidney Care (TKC) systems on chronic kidney disease (CKD) identification and management in Northern Territory (NT) (commenced in 2020)
• Return to Country: A national platform study to return Indigenous renal patients home (commenced in 2019)
• Territory Kidney Care: A care clinical decision support system to facilitate integrated care for people with chronic kidney disease in the Northern Territory 2016

Recently completed projects:

• INFERR Study: Intravenous Iron Polymaltose For Indigenous Patients with High Ferritin Levels on Haemodialysis; A Prospective, Open-Label, Blinded Endpoint, Randomised Controlled Trial (completed December 2025)
• The CKD Consortium: Evaluation of chronic kidney disease identification and management in primary care in three jurisdictions across Australia (completed February 2024)
• Dialysis Models of Care: A partnership project to examine the costs and outcomes of different dialysis models and proximity to home (completed November 2020)
• PK Study: Comparison of immunosuppressant drug pharmacokinetics in Aboriginal and non-Aboriginal Australian kidney transplant recipients (completed June 2020)
• 'Making Sense and Informing Action': Renal Research Knowledge Translation and Exchange with Aboriginal People, Policy Makers and Service Providers (completed March 2020)
• Final evaluation of Top End Outreach Ophthalmology Resource Project (completed November 2017)
• Developing a patient-led component of cultural awareness training for renal services in Alice Springs (completed May 2017)
• Evaluation of CKD management in select NT Aboriginal community controlled health organisations (completed March 2017)
• Central Australian Renal Study Technical Report Update (completed January 2015)
• Systematic review of chronic disease kidney programs (completed December 2014)

1. Pascoe, S., Gillon, D.A., Kamler, P., Aberyaratne, A., Pavlin, N., Gorham, G. Implementing a clinical decision support system in an Aboriginal health service – A qualitative case study. Health Policy and Technology 14:3 (2025). https://doi.org/10.1016/j.hlpt.2025.101010
2. Pascoe, S., Croker, D., Ross, L., Henwood, P., Wilkshire, N., Algy, C., Bob, S., Hall, H., Misener, M. and Gorham, G. The Role of Aboriginal Kidney Health Mentors in the Transplant Journey: A Qualitative Evaluation. Health Promotion Journal of Australia 36: e70000 (2025). https://doi.org/10.1002/hpja.70000
3. Chen, W., Howard, K., Gorham, G., Abeyaratne, A., Zhao, Y., Adegboye, O., Kangaharan, N., Taylor, S., Maple-Brown, L. J., Talukder, M. R., Majoni, S. W., and Cass, A. Cost-Effectiveness of Clinical Decision Support to Improve CKD Outcomes Among First Nations Australians. Kidney International Reports 10: 2 (2025). https://doi.org/10.1016/j.ekir.2024.10.028
4. Gorham, G., Abeyaratne, A., Heard, S., Moore, L., George, P., Kamler, P., Majoni, S.W., Chen, W., Balasubramanya, B., Talukder, M.R., Pascoe, S., Whitehead, A., Sajiv, C., Maple-Brown, L., Kangaharan, N., and Cass, A. Developing an integrated clinical decision support system for the early identification and management of kidney disease—building cross-sectoral partnerships. BMC Medical Informatics and Decision Making 24: 69 (2024). https://doi.org/10.1186/s12911-024-02471-w
5. Lowell A, Jones Y, Aitken R, Baker DR, Lovell J, Togni S, Gon̲d̲arra D, Sometimes B, Smith M, Anderson J, Sharp R, Karidakis M, Quinlivan S, Truong M, and Lawton P.  Why surveys are ‘very hard’: exploring challenges and insights for collection of authentic patient experience information with speakers of Australian First Nations languages. Rural and Remote Health 24: 8380 (2024). https://doi.org/10.22605/RRH8380  
6. Thanasos, V. and Gorham, G. Concept of wellbeing among renal patients in the Top End. Partyline 84 (2023). https://www.ruralhealth.org.au/partyline/article/concept-wellbeing-among-renal-patients-top-end
7. Ralph, A.P., McGrath, S.Y., Armstrong, E., Herdman, R.M., Ginnivan, L., Lowell, A., Lee, B., Gorham, G., Taylor, S., Hefler, M., and Kerrigan, V. Improving outcomes for hospitalised First Nations peoples though greater cultural safety and better communication: the Communicate Study Partnership study protocol. Implement Science 18: 1 (2023). https://doi.org/10.1186/s13012-023-01276-1
8. Gorham, G., Howard, K., Cunningham, J., Lawton, P.D., Ahmed, A.S., Barzi, F., and Cass, A. Dialysis attendance patterns and health care utilisation of Aboriginal patients attending dialysis services in urban, rural and remote locations. BMC Health Services Research 22: 251 (2022). https://doi.org/10.1186/s12913-022-07628-9
9. Gorham, G., Howard, K., Cunningham, J., Barzi, F., Lawton, P.D., and Cass, A. Do remote dialysis services really cost more? An economic analysis of hospital and dialysis modality costs associated with dialysis services in urban, rural and remote settings. BMC Health Services Research 21: 582 (2021). https://doi.org/10.1186/s12913-021-06612-z
10. Hughes, J., Majoni, S., Barzi, F., Harris, T., Signal, S., Lowah, G., Kapojos, J., Abeyaratne, A., Sundaram, M., Goldrick, P., Jones, S., McFarlane, R., Campbell, L., Stephens, D. and Cass, A. (2019). Incident haemodialysis and outcomes in the Top End of Australia. Australian Health Review 44: 2 (2019). https://doi.org/10.1071/AH18230

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