Challenges in the recognition and management of acute kidney injury by hospitals in resource limited settings

Abstract Introduction Acute kidney injury (AKI) is prevalent in low and middle-income countries (LMIC) and is associated with significant morbidity and mortality particularly among hospitalized patients. Successful strategies for the prevention and management of AKI in these countries are dependent on the capacity of primary care centers to provide optimal initial management of patients at risk for this disorder. Methods From December 2018 to February 2019, utilizing mixed methods, we assessed hospital capacity and the knowledge of clinicians relevant to the prevention, diagnosis and management of AKI in Rwanda. A checklist based on KDIGO guidelines and clinical vignette-based assessment tool were used to assess hospital capacity and provider knowledge base respectively. Data were analyzed using stata 13 with findings reported as simple frequencies or means with standard deviation. Multivariate analysis was used to assess factors associated with a higher knowledge score among clinicians. Results Ten hospitals and 193 health care providers from sites throughout Rwanda participated in the survey. Surveyed hospitals were equipped with basic general medical equipment but were deficient in diagnostic tools and medical supplies that would allow the diagnosis and non-dialytic management of AKI. While 20% of the hospitals could offer hemodialysis services, peritoneal dialysis services were non-existent. With regards to knowledge-base, the health care providers demonstrated significant deficiencies in the diagnosis and management of AKI. The mean knowledge score for all health providers was 6.3 (+/- 1.5) out of a maximum of 11, with a mean (+/- SD) score for doctors, nurses and midwives of 6.3+/- 2.05, 6.4 +/- 1.3 and 6.08+/- 1.2 respectively. On multivariate analysis, the length of clinical experience and age of the respondents were significantly associated with participants’ knowledge score. Conclusion This study documents significant barriers to providing optimal management of AKI in primary health care settings in Rwanda (a resource-limited setting). These include lack of specialized medical personnel, significant knowledge gaps among primary health care providers, sub-optimal diagnostic capacity and limited treatment options for detection and management of AKI.