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

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.

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.

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.