Paediatric KRT for Malaria-Associated AKI: Service Availability in Selected African Countries

 

Kidney Replacement Therapy for Children With Acute Kidney Injury Due to Severe Malaria: A Review of Available Services in Selected African Countries

Meaning

Kidney Replacement Therapy (KRT) refers to medical procedures that take over the function of the kidneys when they are no longer able to maintain fluid, electrolyte, and metabolic balance. In children with severe malaria, Acute Kidney Injury (AKI) can occur due to multiple factors such as hemolysis, hypovolemia, and microvascular obstruction. When AKI progresses to life-threatening stages, KRT—primarily peritoneal dialysis (PD), hemodialysis (HD), or continuous renal replacement therapy (CRRT)—is required to remove toxins, correct electrolyte imbalance, and stabilize the child’s condition.

Introduction

Severe malaria is one of the leading causes of pediatric hospital admissions in sub-Saharan Africa. Among its complications, AKI has emerged as a major contributor to morbidity and mortality. Recent studies reveal that up to one-third of children with severe malaria may develop AKI, with those requiring dialysis facing a disproportionately higher risk of death if therapy is not available.

In many African countries, paediatric nephrology services are underdeveloped, and access to KRT is uneven. While tertiary hospitals in upper-middle-income settings such as South Africa may provide a range of dialysis modalities, resource-limited nations often rely on PD as the only feasible KRT option, or lack services altogether. Understanding the availability, advantages, limitations, and barriers to pediatric KRT is critical to improving outcomes for children with malaria-related AKI.

Advantages of KRT in Malaria-Associated AKI

1. Life-saving intervention — Rapid removal of excess fluid and toxins prevents complications like pulmonary edema, hyperkalemia, and uremic encephalopathy.

2. Restores homeostasis — Maintains acid-base and electrolyte balance, giving the kidneys time to recover.

3. Adaptability of modalities — PD is simple and more suitable for small children, while HD is effective for older children and adolescents.

4. Bridge to recovery — Unlike chronic kidney disease, AKI from malaria is often reversible; KRT supports survival until native kidney function recovers.

5. Improves long-term outcomes — Early intervention reduces mortality and prevents progression to chronic kidney disease.

Disadvantages and Challenges of KRT

1. Resource dependence — Dialysis requires trained staff, sterile supplies, and reliable infrastructure, which are often scarce in African hospitals.

2. High cost — Even PD can be unaffordable for families in low-income settings if costs are not subsidized.

3. Risk of complications — Peritonitis in PD, catheter-related infections, and hemodynamic instability in HD.

4. Limited availability — Many district hospitals lack pediatric KRT, and referral delays worsen outcomes.

5. Unequal access — Urban children may access dialysis at referral centers, while rural children often have no options.

In-Depth Details

1. Pathophysiology of Malaria-Associated AKI

• Hemolysis & hemoglobinuria cause pigment nephropathy.

• Sequestration of parasitized red blood cells in renal microvasculature impairs perfusion.

• Hypovolemia & shock reduce renal blood flow.

• Systemic inflammation triggers oxidative stress and tubular injury.
  These mechanisms combine to cause acute tubular necrosis and, if untreated, end-stage AKI requiring KRT.

2. Types of KRT Available for Children in Africa

• Peritoneal Dialysis (PD):

  • Favored in low-resource settings.

  • Requires minimal equipment, is technically simpler, and can be performed in small children.

  • Main limitations: peritonitis, dependence on sterile dialysate supply.

• Hemodialysis (HD):

  • Effective for rapid clearance of toxins and fluid.

  • Requires machines, water treatment systems, vascular access expertise.

  • More available in tertiary hospitals of middle-income countries (South Africa, Nigeria).

• Continuous Renal Replacement Therapy (CRRT):

  • Gold standard in critically ill children with unstable hemodynamics.

  • Rarely available in Africa due to cost and technical complexity.

3. Availability of Services in Selected African Countries

• South Africa: Advanced pediatric nephrology units; PD, HD, and CRRT available in tertiary hospitals. Access remains urban-centered.

• Kenya & Uganda: PD is the primary modality, used in major referral hospitals. HD is limited to older children in tertiary centers. Many district hospitals lack dialysis capacity.

• Nigeria & Ghana: Pediatric PD is available in some teaching hospitals. HD is limited; CRRT is nearly absent. Costs are a major barrier.

• Zambia & Malawi: PD is the most common therapy, often improvised using locally available fluids. Access is limited to referral centers, with little rural coverage.

• Other low-resource settings: Many countries report cases where children die of malaria-induced AKI simply because no KRT service is accessible within reach.

4. Barriers Across the Continent

• Workforce shortages: Few pediatric nephrologists; reliance on general pediatricians with limited training.

• Consumable scarcity: Dialysis fluids, catheters, and tubing often unavailable.

• Financial constraints: Out-of-pocket costs limit access; few national insurance schemes cover pediatric dialysis.

• Late recognition: AKI diagnosis is often delayed due to lack of point-of-care creatinine testing and poor urine output monitoring.

• Infrastructure gaps: Lack of sterile environments, unreliable power, and poor water systems compromise safe dialysis delivery.

Conclusion

KRT is a critical, life-saving intervention for children with severe malaria who develop AKI. While the burden of malaria-related AKI is high in Africa, the availability of pediatric KRT is severely limited and uneven across countries. PD remains the most feasible modality in low-resource settings, but supply chain issues, workforce shortages, and financial barriers restrict its widespread use. To reduce mortality, African health systems must prioritize early AKI detection, scale-up of PD at regional hospitals, workforce training, and supply chain strengthening.

Summary

Kidney Replacement Therapy (KRT) is essential for children with Acute Kidney Injury (AKI) from severe malaria, a leading cause of pediatric mortality in Africa. KRT—especially peritoneal dialysis—offers life-saving benefits but is constrained by limited availability, high costs, and inadequate resources. South Africa has advanced services, while most other African countries rely mainly on peritoneal dialysis at tertiary centers, with large rural gaps. To save lives, African health systems must scale up pediatric KRT capacity, train healthcare providers, improve supply chains, and integrate AKI management into malaria care protocols.