Kidney replacement therapy for acute kidney injury in low-resource settings: Lessons from Africa

Abstract

Acute kidney injury (AKI) is a major cause of preventable morbidity and mortality worldwide, with a disproportionate burden in low-resource settings. In these regions, AKI is commonly community-acquired, affects younger patients, and is frequently related to sepsis, hypovolemia, obstetric complications, nephrotoxins, and infections. Kidney replacement therapy (KRT) is a cornerstone of supportive care for severe AKI, but its use is strongly shaped by local infrastructure, cost, workforce, and supply chains. Current evidence does not show consistent superiority of continuous KRT, intermittent hemodialysis (IHD), prolonged intermittent KRT, or peritoneal dialysis (PD) in broad AKI populations with respect to survival or kidney recovery. Accordingly, modality choice should be individualized according to patient characteristics and local feasibility. In many African and other low-resource settings, IHD and PD remain the dominant modalities because they are more accessible and scalable than continuous therapies. This review discusses how resource limitations shape AKI KRT practice, with emphasis on Africa, and outlines pragmatic strategies to improve equitable access to life-saving renal support.

Key Words: Acute kidney injury; Kidney replacement therapy; Low-resource settings; Africa; Hemodialysis; Peritoneal dialysis; Continuous kidney replacement therapy; Critical care nephrology

Core Tip: In low-resource settings, the critical question in acute kidney injury (AKI) is often not which kidney replacement therapy modality is theoretically superior, but which one can be started quickly, delivered safely, and sustained reliably. Because comparative trials have not shown clear outcome superiority of one modality across all patients, context-adapted use of intermittent hemodialysis and peritoneal dialysis, supported by earlier diagnosis, better referral pathways, and workforce training, offers the most realistic strategy to reduce preventable deaths from AKI in Africa and similar settings.

INTRODUCTION

Acute kidney injury (AKI) is a common clinical syndrome associated with increased short-term mortality, prolonged hospitalization, higher costs, and long-term risks of chronic kidney disease and cardiovascular events[1-4]. Although AKI is a global problem, its epidemiology differs markedly between high-income and low-resource settings. In high-income countries, AKI is often hospital-acquired, develops in older individuals with multiple comorbidities, and frequently occurs in intensive care settings. By contrast, in many countries in Africa and other low-resource regions, AKI is commonly community-acquired, affects younger and previously healthy individuals, and is frequently related to preventable or treatable disorders such as sepsis, diarrheal illness, hypovolemia, obstetric complications, envenomation, and exposure to nephrotoxins[5-9].

The International Society of Nephrology by 25 initiative and subsequent global AKI programs highlighted the unacceptable burden of preventable deaths from untreated AKI and emphasized that many patients in low- and lower-middle-income countries die not because AKI is irreversible, but because diagnosis is delayed and supportive care, including kidney replacement therapy (KRT) when needed, is unavailable or unaffordable[5-7]. This problem is especially important in Africa, where disparities in kidney care infrastructure remain substantial and access to acute dialysis is highly variable across and within countries[8-12].

KRT is a major pillar of supportive care in severe AKI. KRT is used in this review as an umbrella term for therapies that temporarily or permanently replace essential kidney functions. In the context of AKI, however, KRT refers mainly to temporary kidney support delivered by intermittent hemodialysis (IHD), prolonged intermittent KRT (PIKRT), continuous KRT (CKRT), or acute peritoneal dialysis (PD). Kidney transplantation represents definitive kidney replacement in irreversible kidney failure, but it is not an acute therapeutic option for most patients with AKI. Therefore, throughout this manuscript, the term KRT refers to dialysis-based supportive therapy for severe, potentially reversible AKI unless otherwise specified. However, KRT practice is inseparable from context. Modality selection depends not only on hemodynamic status, catabolic burden, and fluid balance, but also on whether machines, sterile consumables, vascular access materials, laboratory support, water treatment systems, trained personnel, and financing are available. In low-resource settings, the best KRT modality is often the one that can be delivered promptly, safely, and consistently. This review summarizes the evidence supporting current AKI KRT modalities and discusses how resource limitations shape real-world practice, taking Africa as a representative example.

INDICATIONS AND TIMING OF KRT IN AKI

The classical indications for KRT in AKI remain refractory hyperkalemia, severe metabolic acidosis, fluid overload causing respiratory compromise, and clinically significant uremic manifestations such as encephalopathy or pericarditis[1,13]. Additional considerations include persistent oliguria or anuria, severe azotemia in the appropriate clinical context, and the need to facilitate nutritional or fluid management in critically ill patients.

Over the past decade, randomized trials have challenged the notion that KRT should be started pre-emptively in all patients with severe AKI before conventional indications emerge. The AKIKI trial found no mortality benefit with an early strategy compared with a delayed strategy[14]. Similar findings were reported in the IDEAL-ICU trial among patients with septic shock and severe AKI[15], and the STARRT-AKI trial showed that an accelerated strategy increased KRT exposure without improving 90-day survival[16]. These data support individualized decision-making rather than automatic early initiation.

For low-resource settings, this evidence has practical implications. Scarcity of dialysis resources makes triage unavoidable, but delayed initiation should not mean therapeutic nihilism. Rather, clinicians should combine close monitoring with early correction of reversible causes and reserve urgent KRT for those with life-threatening indications or ongoing metabolic and volume derangements that cannot be controlled conservatively. This approach requires not only clinical judgment but also minimal laboratory capability, reliable urine output assessment, and a clear referral pathway. Recent updates from the KDIGO 2026 AKI/acute kidney disease guidance further emphasize the continuum linking AKI, acute kidney disease, and subsequent chronic kidney disease. The updated framework reinforces individualized KRT initiation, optimization of supportive care, structured post-AKI follow-up, and greater emphasis on recovery trajectories rather than dialysis initiation alone. Although these recommendations are globally applicable, implementation in many African settings requires adaptation to local constraints in diagnostics, workforce availability, and KRT infrastructure[10].

MODALITIES OF KRT IN AKI

Acute KRT is delivered through four main modalities: CKRT, IHD, PIKRT, and PD. CKRT provides slow, continuous removal of solutes and fluid and is often favored in hemodynamically unstable intensive care patients. Its advantages include better tolerance of ultrafiltration, reduced osmotic shifts, and flexibility in fluid management. However, CKRT requires specialized machines, uninterrupted supplies of replacement or dialysate fluids, anticoagulation strategies, intensive nursing input, and continuous monitoring[17,18].

IHD remains the most widely available extracorporeal modality worldwide. It is highly effective for rapid correction of hyperkalemia, acidosis, and overt uremia, and it is often the default acute KRT modality in centers that already operate chronic hemodialysis programs. However, IHD depends on reliable water treatment, electricity, dialysis machines, consumables, vascular access, and trained staff, and rapid fluid or solute shifts may limit tolerability in unstable patients[17,19].

PIKRT, including sustained low-efficiency dialysis and related approaches, occupies a middle ground between IHD and CKRT. It can improve hemodynamic tolerance while using conventional hemodialysis infrastructure for extended sessions. Yet it still depends on extracorporeal equipment, trained personnel, and consistent supplies, which restricts its use in many low-resource hospitals[19].

PD is increasingly recognized as a valid modality for AKI. It avoids extracorporeal circulation, does not require a water treatment plant, and can often be implemented with lower infrastructure requirements than hemodialysis. These advantages are particularly important in children, in hospitals without established dialysis units, and in regions with unreliable electricity or limited intensive care capacity[20-23].

COMPARATIVE EVIDENCE: NO UNIVERSAL WINNER

Comparative studies have not shown consistent superiority of one acute KRT modality over another in terms of mortality or kidney recovery. Trials comparing CKRT and IHD have generally failed to show a clear survival advantage for either strategy[17,18,24]. A secondary analysis of the AKIKI and IDEAL-ICU databases similarly found no survival difference according to initial modality choice[25]. Thus, although CKRT is often preferred for unstable patients in highly resourced ICUs, this preference should not be interpreted as universal evidence of better outcomes.

The place of PD has also evolved. Earlier skepticism was driven by concerns regarding slower solute clearance, limited ultrafiltration in some circumstances, and risk of peritonitis or leaks. More recent data and guidelines support PD as an effective treatment for AKI in selected patients. The 2020 International Society for Peritoneal Dialysis (ISPD) guideline update for adults states that PD is an acceptable therapy for AKI, especially where extracorporeal therapies are not feasible[20]. Pediatric guidance similarly supports acute PD as an important modality, particularly in infants and small children[21]. Randomized and observational studies have shown that PD can achieve outcomes comparable to extracorporeal therapies in many clinical settings, although extracorporeal therapies may offer faster correction of severe metabolic abnormalities and greater ultrafiltration when urgently required[22,23].

Several systematic reviews and meta-analyses comparing CKRT and IHD have similarly failed to demonstrate consistent superiority of one modality for mortality or kidney recovery outcomes. While CKRT may provide better hemodynamic stability and fluid management in selected critically ill patients, these physiologic advantages have not translated into universal outcome benefits. Current evidence therefore supports individualized modality selection based on patient characteristics, local expertise, and resource availability rather than adherence to a rigid hierarchy of KRT modalities. Importantly, modality selection should be viewed as a patient-centered and resource-sensitive decision rather than a competition between technologies, since delayed initiation of an available modality is consistently associated with worse outcomes than timely delivery of an appropriate locally available therapy[20-23]. The practical conclusion is that the "best" modality is context-dependent. In resource-limited environments, feasibility and reliability are not secondary considerations; they are central determinants of outcome.

WHY LOW-RESOURCE SETTINGS DIFFER

The delivery of acute KRT depends on more than machines. It requires an ecosystem: Timely diagnosis, vascular or peritoneal access, laboratory testing, infection control, dialysis consumables, water, electricity, trained nurses and technicians, and the financial means to sustain treatment. Failure at any step can render an otherwise appropriate modality unusable.

These constraints are particularly visible in Africa. Regional reviews have documented large disparities in dialysis access, with some centers able to provide acute hemodialysis whereas others lack any dialysis capability at all[8-12]. Out-of-pocket payment remains a major barrier in many countries, leading to delayed initiation, incomplete treatment courses, or outright denial of KRT[9-12]. Workforce limitations compound the problem; shortages of nephrologists, pediatric nephrologists, dialysis nurses, and technicians make complex modalities difficult to scale. Even where HD machines exist, interruptions in water or power supply can compromise care.

Another defining issue is late presentation. Many patients first present to health facilities after several days of illness, often with advanced sepsis, profound dehydration, severe anemia, or multiorgan dysfunction. Limited access to creatinine testing and poor recognition of early AKI at district-level facilities further delay referral[6,7,26]. Thus, by the time KRT is considered, disease severity may be high and the margin for recovery narrow.

KRT PRACTICE IN AFRICA: THE DOMINANT ROLE OF IHD AND PD

In much of Africa, IHD and PD are the most commonly used KRT modalities for AKI. CKRT is confined mainly to better-resourced tertiary or private intensive care units because of its cost and technical demands. PIKRT is used selectively where HD machines and trained teams allow adaptation of chronic dialysis infrastructure (Table 1).

Table 1 Practical comparison of kidney replacement therapy modalities for acute kidney injury in low-resource settings.

Modality	Main advantages	Main limitations	Best fit in low-resource settings
CKRT	Excellent hemodynamic tolerance; precise fluid control	High cost; machine dependence; intensive nursing; continuous consumables	Limited to well-resourced ICUs
IHD	Rapid correction of hyperkalemia and acidosis; familiar; can use existing chronic HD units	Needs water treatment, power, machines, vascular access, trained staff; may worsen hypotension	Stable adults in centers with functioning HD infrastructure
PIKRT	Better hemodynamic tolerance than IHD; can use standard HD machines over longer sessions	Still infrastructure-dependent; staff time intensive	Intermediate option where HD exists but CKRT is not feasible
PD	Low infrastructure requirement; no water treatment plant; useful in children and unstable patients; relatively scalable	Slower solute clearance in some settings; risk of peritonitis or leaks; requires catheter and PD expertise	Hospitals without reliable extracorporeal dialysis, pediatric AKI, remote or lower-level facilities

CKRT: Continuous kidney replacement therapy; AKI: Acute kidney injury; HD: Hemodialysis; IHD: Intermittent hemodialysis; ICU: Intensive care unit; PD: Peritoneal dialysis; PIKRT: Prolonged intermittent kidney replacement therapy.

IHD is often the dominant extracorporeal modality because it aligns with existing chronic dialysis services. When a dialysis unit is available, acute patients can sometimes be accommodated with temporary vascular access and modified prescriptions. Its strengths include rapid potassium control, widespread clinician familiarity, and the possibility of leveraging existing dialysis staff. Its limitations are equally important: Transport to dialysis units may be difficult for unstable patients, hemodynamic intolerance is common in shock states, and treatment delivery depends on infrastructure that is frequently fragile[9,17,19].

PD remains especially valuable where extracorporeal support is absent, unreliable, or unaffordable. Although comprehensive continent-wide utilization data remain limited, reports from the Saving Young Lives initiative and regional observational studies demonstrate that acute PD can be successfully implemented across multiple African countries with acceptable patient outcomes and relatively low infrastructure requirements. These experiences highlight the feasibility of PD as a scalable KRT option in settings where extracorporeal therapies remain unavailable or inaccessible. The ISPD adult and pediatric guidelines endorse PD as a suitable modality for AKI, and programmatic experience from Saving Young Lives has shown that acute PD programs can be established sustainably in low-resource regions, including in Africa[20,21,27,28]. PD is particularly attractive in pediatrics, where vascular access and extracorporeal blood volume pose additional technical challenges. It is also useful in remote hospitals, smaller centers, and facilities facing recurrent supply interruptions.

The main drawbacks of PD include slower correction of severe hyperkalemia in some cases, lower clearance in highly catabolic states, risk of leaks or peritonitis, and the need for appropriate catheter placement and prescription expertise. Nonetheless, these limitations should be weighed against the reality that in many settings the alternative is no KRT at all.

PRACTICAL MODALITY SELECTION IN LOW-RESOURCE SETTINGS

In low-resource settings, particularly in Africa, KRT modality selection in adult AKI should be guided primarily by patient physiology and subsequently aligned with locally available resources (Figure 1 and Table 2). A pragmatic decision framework for low-resource settings should ask five questions: Is there a life-threatening indication for urgent KRT? Which modality can be started fastest? Can it be delivered safely with the staff and monitoring available? Can treatment be sustained over the next 48-72 hours? Is referral feasible if the chosen modality proves inadequate?

Figure 1 Algorithm for kidney replacement therapy modality selection in adult acute kidney injury in Africa. The algorithm first confirms the need for kidney replacement therapy (KRT) based on life-threatening complications (refractory hyperkalemia, severe metabolic acidosis, pulmonary edema, uremic manifestations, or rapidly rising nitrogenous waste) despite optimal medical management, then stratifies patients by hemodynamic status (stable/borderline vs markedly unstable) and availability of intensive care unit (ICU)-level monitoring. Local resource assessment distinguishes four settings: A: Centers with only intermittent hemodialysis (IHD); B: Centers with IHD plus sustained low-efficiency dialysis (SLED); C: Tertiary ICUs with IHD, SLED and continuous KRT (CRRT); and D: Hospitals without extracorporeal therapies but with capacity for acute peritoneal dialysis (PD). In stable adults, IHD is recommended as first-line where available, whereas in unstable patients SLED is preferred in intermediate-resource ICUs and CRRT in tertiary ICUs, with step-down from CRRT to SLED to IHD as hemodynamics improve. In facilities lacking extracorporeal KRT, or when cost or vascular access precludes IHD/CRRT, acute PD is recommended as the primary modality following International Society for Peritoneal Dialysis acute kidney injury dosing and aseptic technique, except in patients with major intra-abdominal contraindications. AKI: Acute kidney injury; KRT: Kidney replacement therapy; IHD: Intermittent hemodialysis; PD: Peritoneal dialysis; SLED: Sustained low-efficiency dialysis; CRRT: Continuous kidney replacement therapy.

Table 2 Major barriers and pragmatic solutions for acute kidney injury kidney replacement therapy in Africa.

Barrier	Effect on care	Pragmatic response
Late recognition of AKI	Delayed referral and delayed KRT	Risk-based screening, urine output monitoring, point-of-care creatinine where possible
Limited dialysis infrastructure	No access to CKRT or HD in many centers	Build one dependable pathway, often acute PD or adapted emergency HD
Consumable shortages	Interrupted or incomplete treatment	Central procurement, protected stock, local supply-chain planning
Workforce shortages	Inability to deliver complex therapies safely	Multidisciplinary training for physicians, nurses, and technicians
High out-of-pocket costs	Treatment refusal, delay, early discontinuation	Public financing, emergency coverage, donor-supported start-up programs
Weak referral systems	Patients arrive with advanced complications	Standard referral criteria and transport pathways between district and tertiary centers

AKI: Acute kidney injury; CKRT: Continuous kidney replacement therapy; HD: Hemodialysis; KRT: Kidney replacement therapy; PD: Peritoneal dialysis.

Stable adults with severe hyperkalemia, pulmonary edema, or overt uremic symptoms may benefit most from IHD when a functioning dialysis unit is available. Hemodynamically unstable patients, children, and patients in hospitals without reliable HD infrastructure may be better served by PD. PIKRT can be useful where dialysis machines exist but CKRT consumables are unavailable or unaffordable. The key is not adherence to a hierarchy imported from high-income ICUs, but creation of context-specific pathways that standardize decisions and reduce delay.

STRATEGIES TO IMPROVE ACCESS

Improving AKI outcomes in low-resource settings requires a systems approach. First, earlier recognition of AKI must be prioritized through clinician education, simple risk assessment tools, point-of-care creatinine testing where possible, and protocolized management of sepsis, dehydration, and obstetric emergencies[6,7,26]. Second, hospitals should develop at least one dependable acute KRT pathway rather than attempting to offer multiple unreliable modalities. In many centers, this may mean strengthening acute PD capability; in others, it may mean adapting existing chronic HD services for emergency AKI care.

Third, training must extend beyond nephrologists to emergency physicians, intensivists, internists, pediatricians, obstetric teams, surgeons, and nurses, since many AKI patients present outside nephrology units. Fourth, governments and institutions should treat AKI care as an essential service. Sustainable financing for consumables, vascular access, PD catheters, and basic laboratory testing may save more lives than investment in a small number of high-end ICU devices. Finally, regional registries and implementation research are needed to define burden, identify barriers, and track outcomes in African populations[8-12,29,30].

FUTURE DIRECTIONS

Future progress in AKI care in Africa will likely depend less on identifying a universally superior dialysis modality and more on improving delivery systems and early intervention. Emerging priorities include expansion of acute PD programs, wider use of point-of-care creatinine testing, implementation of AKI recognition bundles, development of affordable monitoring technologies, tele-nephrology support for remote hospitals, and establishment of multicenter AKI registries. Although pharmacologic therapies capable of reversing established AKI remain limited globally, several ongoing international studies are evaluating biomarker-guided interventions, anti-inflammatory therapies, and kidney-protective strategies. Equally important is the establishment of multicenter African pragmatic clinical trials evaluating context-adapted AKI care pathways, simplified dialysis protocols, and implementation strategies rather than merely comparing technologies developed for high-resource intensive care settings. Such studies are more likely to generate evidence directly applicable to African health systems[29,30].

CALL TO ACTION FOR AKI CARE IN AFRICA

Despite advances in AKI management, preventable AKI-related mortality remains unacceptably high across many African countries because of delayed diagnosis, limited access to KRT, workforce shortages, and fragile healthcare systems. Improving outcomes requires strengthening sustainable AKI care pathways rather than expanding costly technologies alone. Priorities include standardized AKI recognition and referral protocols, improved laboratory and point-of-care diagnostic capacity, workforce training, expansion of acute peritoneal dialysis and adapted hemodialysis services, reliable procurement of dialysis consumables, and establishment of national and regional AKI registries. Equally important is the development of African-led implementation research and pragmatic multicenter clinical trials to generate evidence applicable to resource-limited settings. The long-term goal is equitable access to timely AKI diagnosis, appropriate KRT, and structured post-AKI follow-up for all patients, regardless of geographic or socioeconomic circumstances. The strategic priorities summarized in Table 3 provide a practical roadmap for strengthening AKI care across African health systems through coordinated action in clinical practice, research, education, and health policy[29,30].

Table 3 Strategic priorities for strengthening acute kidney injury care in Africa.

Priority	Current challenge	Recommended action	Expected impact
Early AKI recognition	Delayed diagnosis and referral	Implement AKI risk assessment, urine output monitoring, and point-of-care creatinine testing	Earlier diagnosis and reduced disease severity at presentation
Standardized referral pathways	Delayed access to nephrology services	Develop national referral algorithms linking district and tertiary hospitals	Faster initiation of appropriate KRT
Expansion of acute PD programs	Limited access to extracorporeal KRT	Scale up acute PD services, particularly in secondary and rural hospitals	Increased KRT availability and reduced preventable mortality
Adaptation of existing HD infrastructure	Limited CKRT availability	Optimize emergency use of chronic HD units and SLED where feasible	Improved access to life-saving dialysis
Workforce development	Shortage of nephrologists and dialysis personnel	Expand multidisciplinary education for physicians, nurses, and technicians	Safer and more sustainable AKI care
Affordable access to dialysis consumables	Frequent treatment interruption due to supply shortages	Strengthen procurement systems and encourage local manufacturing	Improved continuity of dialysis services
National AKI registries	Limited epidemiological and outcome data	Establish multicenter African AKI registries	Better quality improvement and health policy planning
African pragmatic clinical trials	Limited region-specific evidence	Conduct implementation-focused multicenter trials evaluating context-adapted AKI care pathways	Generation of evidence directly applicable to African healthcare systems
Government commitment and financing	High out-of-pocket expenditure	Integrate AKI care into national health strategies and universal health coverage	Improved equity and long-term sustainability of AKI care

AKI: Acute kidney injury; CKRT: Continuous kidney replacement therapy; HD: Hemodialysis; KRT: Kidney replacement therapy; PD: Peritoneal dialysis; PIKRT: Prolonged intermittent kidney replacement therapy; SLED: Sustained low-efficiency dialysis.

CONCLUSION

AKI in low-resource settings represents both a nephrology emergency and a health-systems challenge. Current evidence does not support universal superiority of CKRT, IHD, PIKRT, or PD for mortality or kidney recovery. Accordingly, modality selection should be individualized according to patient physiology, available expertise, and local healthcare capacity. In many African settings, the greatest determinant of outcome is not the theoretical superiority of a dialysis modality but whether safe kidney support can be initiated promptly and sustained reliably. Future progress will therefore depend less on technological advances alone and more on strengthening health systems capable of delivering equitable, timely, and context-appropriate AKI care.