Pediatric acute kidney injury in Rwanda: awareness, early detection, and timely management to improve outcomes, a multi-center mixed method study.

BACKGROUND

Acute kidney injury in children is a serious but often overlooked condition in low-resource settings. In Rwanda, although referral hospitals provide advanced care, most children are managed at district hospitals, where limited diagnostic services and low provider awareness may delay diagnosis. We assessed healthcare providers' knowledge of pediatric AKI, audited real-world case management, and evaluated whether a brief training intervention could improve early detection and care.

METHODS

We conducted a mixed-method study in six Rwandan hospitals affiliated with the University Teaching Hospital of Kigali from 2024 to 2025. A cross-sectional survey assessed provider knowledge, followed by retrospective and prospective case audits of pediatric AKI management. Cases aged 1 month to 14.9 years were screened using serum creatinine ≥ 1.0 mg/dL, and 155/156 met KDIGO Serum Criteria for AKI. A KDIGO-based educational workshop was delivered on April 25, 2025; patients admitted before formed pre-intervention cohort (n = 138) and post-intervention cohort (n = 18). Care quality was assessed using nine indicators adapted from the Recognition-Action-Results framework. Multivariable and stratified analyses were performed.

RESULTS

Among 166 providers (65.7% female; 51.2% nurses), the mean knowledge score was 2.1/5.0 (42%), with only 3.6% achieving > = 80%. Knowledge gaps were consistent across professional categories and hospitals, although 89.8% expressed willingness to adopt AKI guidelines. In the 156 pediatric cases (mean age was 6.6 +/- 5.3 years; 54.5% male), 76.3% presented with KDIGO Stage 3 AKI, most commonly associated with acute gastroenteritis (33.3%). Baseline care quality was poor with low documentation of staging (5.8%), urine output monitoring (3.6%), and follow-up creatinine testing (27.5%); however, laboratory investigations were performed in 87.7% of cases. After training, follow-up creatinine monitoring increased modestly to 33.3%. Composite care quality showed non-significant improvement (40.6% vs. 44.4%; OR 1.17, 95% CI 0.44-3.15; p = 0.802). Overall mortality was 9.6% (15/156) with hypovolemic shock (OR 8.73, p = 0.008), severe dehydration (OR 5.29, p = 0.009), and hypernatremia (OR 4.18, p = 0.045) as independent predictors.

CONCLUSION

Pediatric AKI remains underrecognized in Rwandan district hospitals, with critical gaps in staging and monitoring. Training improved selected practices but did not translate into improved outcomes. Sustained improvements require mentorship, standardized protocols, and system-level support. Larger prospective studies are needed to confirm impact.