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 (AKI) in children is a serious but often overlooked condition in low-resource settings. In Rwanda, the health system is structured into a pyramid with national referral hospitals at the top. Nevertheless, most children receive care at district hospitals, where limited diagnostic tools and low provider awareness may delay recognition. We set out to assess healthcare providers' knowledge, review real-world case management, and evaluate whether a training intervention could improve early detection and care of pediatric AKI patients. Methods We conducted a mixed-method project in six Rwandan hospitals affiliated with the University Teaching Hospital of Kigali (CHUK) as referral centers from 2024–2025. First, a cross-sectional survey was used to assess providers’ knowledge of AKI and appropriate management. Second, we reviewed pediatric case files for evidence of AKI recognition, staging, investigations, management, and outcomes. On April 25, 2025, we delivered a training workshop onsite on pediatric AKI patients on the basis of the KDIGO guidelines. Patients admitted before this date were classified as preintervention patients, and those admitted after this date were classified as post-intervention patients. We compared indicators between the two periods. Multivariate analysis was used to assess associated factors and correlations. Results Among 166 healthcare providers (65.7% female), baseline knowledge scores averaged 2.1/5.0 (42%), with only 3.6% achieving adequate performance (≥ 80%). The knowledge gaps were uniform across professional categories (p = 0.312) and hospitals (p = 0.756). Despite their low level of knowledge, 89.8% expressed a willingness to implement AKI guidelines. In the case audit (n = 166), patients who were aged (1 month to 14.9 years) and presented with elevated creatinine levels of more than 1 mg/dl or 88 mmol/l were enrolled (139 preintervention (n = 139, 83.74%) and postintervention (n = 27, 16.26%). The median age was 2,834 ± 1,925 (pre) and 2,912 ± 1,756 (post), with no significant difference between groups (p = 0.837). Male patients comprised 57.8% (96/166) of the total cohort. Multivariate analysis training significantly improved AKI recognition rates (30.9% vs 63.0%, p = 0.003), with trends toward better staging documentation and monitoring practices. The crude mortality rate was 8.6%, with no significant difference pre/post. Mortality analysis revealed neurological symptoms (OR 8.05), shock states (OR 6.80), and severe malnutrition (OR 5.43) as key predictors of death, and a multiple serum creatinine level was associated with lower odds of death (OR 0.20, p = 0.037). Conclusion Pediatric AKI remains underrecognized in Rwandan district hospitals, with major gaps in knowledge, staging, and monitoring. Training improved recognition and follow-up creatinine testing but did not reduce mortality. Providers showed strong willingness to adopt guidelines, suggesting potential for practice change. To sustain gains, mentorship, standardised checklists, and system-level support are needed. Our small post-intervention sample and reliance on retrospective records may underestimate care quality. Larger prospective studies are required to confirm findings and assess long-term impact on outcomes.