Pediatric kidney replacement therapies in low-to-middle income countries: a review and white paper.

Acute kidney injury (AKI) disproportionately impacts children in low- and middle-income countries (LMICs), where up to 85% of AKI cases occur. As for pediatric chronic kidney disease (CKD), the true burden in LMICs remains unclear, as many cases go undiagnosed early, and other children succumb without adequate treatment. Unfortunately, these disparities result from limited access to kidney replacement therapy (KRT), kidney laboratory and imaging resources, healthcare provider shortages, and financial barriers. Pediatric kidney disease in LMICs often remains undiagnosed until advanced stages, magnified by limited access to lifesaving KRT, leading to significantly higher mortality rates compared to high-income countries. Additional challenges include community-acquired AKI from preventable causes such as infections and dehydration, compounded by the use of nephrotoxic remedies, poor healthcare seeking behavior, and lack of monitoring. Pediatric data for this vulnerable population is lacking. For children with CKD, barriers to sustained treatment-including dialysis and transplantation-further worsen outcomes. Socioeconomic inequalities, geographic barriers, and cultural factors additionally exacerbate outcomes. Efforts to address these disparities include implementing affordable, resource-efficient peritoneal dialysis (PD) programs, enhancing healthcare worker training, and adopting innovative diagnostic technologies. Successful international collaborations, such as the Sister Renal Program, Saving Young Lives, and the Affordable Dialysis Project, have demonstrated the potential for improving access and outcomes. Advocacy for sustainable government policies, resource allocation, and integration of community-based approaches is critical. This paper highlights global inequities in pediatric nephrology care and proposes targeted strategies to enhance diagnostics, treatment, and management of AKI and CKD in LMICs. A call to action is issued to foster international collaboration and prioritize the needs of resource-limited regions.