A qualitative study of nephrologists’ perspectives on implementing a nephrology rapid response model for acute kidney injury

Abstract

Introduction

Acute kidney injury (AKI) poses major health and economic burdens, especially in low-resource settings like Palestine. This study explores nephrologists’ perspectives on implementing the Nephrology Rapid Response Team (NRRT) model, highlighting key barriers, facilitators, and strategic priorities to improve AKI care.

Study Design

A qualitative, exploratory study design was employed to gain in-depth nephrologists’ perspectives on the feasibility of implementing the Nephrology Rapid Response Team (NRRT) model in Palestinian hospitals.

Methods

Thirteen board-certified nephrologists were recruited using purposive sampling. Semi-structured interviews were conducted between January and May 2024, with data transcribed verbatim and analyzed thematically using MAXQDA Analytics Pro software. Thematic analysis identified key facilitators, barriers, and recommendations. Rigorous methodological strategies ensured the credibility, dependability, and transferability of the findings.

Results

Five enablers themes emerged that could facilitate integration of the model: strategic backing from the Ministry of Health, a growing orientation toward prevention-driven healthcare policies, enhanced multidisciplinary collaboration with early nephrologist engagement, institutional endorsement through hospital-based systems, and the progressive adoption of technological innovations such as electronic alert systems and novel biomarkers. On the other hand, five dominant barrier themes emerged. These include systemic governance and policy fragmentation, financial and operational limitations, a pronounced shortage of nephrology specialists, insufficient awareness and prevention frameworks, and weak collaboration and surveillance systems—particularly the lack of a national renal registry. Despite these obstacles, nephrologists expressed optimism, offering three central recommendations to support sustainable implementation. These include systemic policy and governance reforms, investments in nephrology education and training programs, and the expansion of public awareness and prevention strategies through primary care engagement. Together, these strategies represent a foundational roadmap for overcoming structural challenges and AKI care delivery through the NRRT model.

Conclusions

This study highlights the Ministry of Health’s critical role in leading reforms for NRRT implementation, emphasizing prevention, technology, and capacity-building as priorities to improve nephrology care.

Clinical trial number

Not applicable.

Background

Acute kidney injury (AKI), characterized by a sudden decline in kidney function, is a significant contributor to patient morbidity and mortality in hospital settings. It is linked to prolonged hospital stays and a tenfold increase in inpatient mortality. Additionally, AKI independently elevates the risk of progressing to chronic kidney disease (CKD), end-stage kidney disease (ESKD), cardiovascular complications, and a heightened susceptibility to infections [1]. AKI affects an estimated 13.3 million people annually, with 85% of cases occurring in developing countries. Beyond direct kidney-related complications, AKI also increases the likelihood of requiring long-term hemodialysis and raises the risk of recurrent hospitalizations due to multi-organ failure. AKI is believed to contribute to approximately 1.7 million deaths each year [2].

According to the Palestinian Ministry of Health’s (MOH) Annual Reports until 2025, more than 3,500 patients across the Gaza Strip and West Bank (including 2,300 in the West Bank alone) currently suffer from ESKD [3]. While not all cases of ESKD are directly secondary to AKI, the growing burden of AKI contributes significantly to disease progression, long-term dialysis dependence, and health system strain. As shown in Fig. 1, dialysis-dependent patients in the West Bank alone have increased by 108% over the past decade from 1,014 in 2015 to 2,300 in 2025. Escalated worsening epidemiological trajectory trend, unfortunately, coincides with the absence of a centralized renal registry in Palestine to capture the incidence, etiology, or outcomes of AKI. This critical surveillance gap hinders timely diagnosis, delays appropriate care, and restricts evidence-based national planning.

Fig. 1.

Trends in dialysis utilization and mortality in the west bank (2015–2025). Source: Palestinian ministry of health [3]. Data for 2024–2025 derived from official unpublished records

From a financial perspective, the economic impact of nephrology care in Palestine is profound. A study by Younis et al. [4] estimated the average cost of a kidney transplant at $16,277 in the first year, with annual hemodialysis costs reaching $16,085 per patient. With more than 2,300 dialysis-dependent patients in the West Bank alone, the combined annual cost of dialysis services is projected to exceed $50 million. Such figures reflect a broader international trend highlighted by Jha et al. [5] that shows exponential increases in treatment costs as CKD advances.

These clinical and economic realities reinforce a strategic imperative: shifting nephrology care in LMICs, including Palestine, from reactive, late-stage interventions to proactive and preventive strategies. Structured screening programs, AKI risk stratification, and multidisciplinary nephrology response teams offer a path to reducing the progression of kidney disease and alleviating both human and financial suffering. Given these challenges, there is momentous need for early detection and robust public health polices to mitigate AKI progression and improve long-term prognosis inspired from the 5-R approach proposed by the ISN (Interenational socitey of Nephrology)‘0 death by 2025 project: risk assessment, recognition, response, renal support and rehabilitation, the first three Rs concern the prevention area.

The Nephrology Rapid Response Team (NRRT) is a multidisciplinary model designed to enhance early detection, risk stratification, and timely intervention for AKI. As illustrated in Fig. 2, the NRRT framework outlines a structured pathway for managing AKI within the first 12–48 hours, integrating electronic alert systems, laboratory assessments, and team-based care to ensure rapid nephrology consultation. This model, adapted from Rizo-Topete et al. [6], emphasizes AKI risk assessment through clinical evaluation, history, examination findings, and laboratory data. The NRRT framework follows a structured AKI Risk Assessment (ARA) model, which evaluates clinical scenarios, patient history, physical examination findings, and laboratory results, including biomarker-based risk identification. This approach facilitates rapid intervention, minimizes the reliance on invasive treatments like dialysis, and strengthens post-AKI monitoring to prevent chronic kidney disease (CKD) progression [6]. However, before adopting this model in Palestinian hospitals, it is crucial to understand the specific barriers and facilitators nephrologists encounter in managing AKI, in addition to exploring general recommendations to enhance the quality of nephrology care.

Fig. 2.

Structure of the nephrology rapid response team (NRRT) Model. This figure outlines the NRRT pathway for early AKI detection, including risk stratification, use of biomarkers, electronic alert systems, and multidisciplinary nephrology intervention

This study aims to explore the perspectives of nephrologists on implementing the NRRT model in Palestinian hospitals. By examining the facilitators, barriers, and general recommendations for NRRT implementation, this research seeks to provide valuable insights for policymakers. Such insights can guide the development of a national strategy to improve AKI management, reduce its associated morbidity, mortality, and healthcare costs, and enhance nephrology services in Palestine.

Methods

Study design

A qualitative, exploratory approach was conducted to analyze the perspectives of nephrologists on the feasibility of implementing the NRRT model in hospitals across the West Bank, Palestine. The in-depth interview guide used in this study was specifically developed by the author for this research, which was reviewed by experts and has not been previously published. An English version of the interview guide has been uploaded as a supplementary file and is cited in the manuscript accordingly. This approach was selected to gain deeper insights into the barriers, facilitators, and recommendations influencing AKI management.

Data collection

Data collection took place between [January, 2024] and [May,2024]. Nephrologists were purposively selected from nephrology departments in Palestinian hospitals located across the West Bank-Palestine. Semi-structured, face-to-face interviews were used as the primary method of data collection. Each interview was conducted in the participant’s office or a private hospital room to ensure confidentiality and comfort.

Participant selection

While AKI is inherently interdisciplinary, this study focused exclusively on board-certified nephrologists due to their central role in clinical decision-making, specialist referral protocols, and nephrology-specific policy development. This focused sampling enabled an in-depth exploration of nephrologists’ perspectives on the feasibility of the NRRT. The exclusion of other clinical stakeholders is acknowledged as a limitation, and future research is encouraged to include multidisciplinary views.

Data saturation and sample justification

Data saturation was reached between the 9th and 10th interviews, at which point no new codes or concepts were emerging from the data. This assessment was made through an iterative coding process in which each new transcript was analyzed in comparison with the developing thematic framework. Despite reaching saturation, data collection continued until all 13 board-certified nephrologists practicing in the West Bank had been interviewed. This decision was guided by methodological rigor and supervisory recommendation, ensuring full utilization of the total available population and enhancing the study’s depth and contextual variation.

Trustworthiness

Credibility was ensured through triangulation (peer debriefing, expert feedback), member checking, and verbatim transcription. Dependability was enhanced by a detailed audit trail, and confirmability was supported through external review of codes and theme validation. Transferability was considered through rich contextual descriptions of the Palestinian nephrology infrastructure, enabling comparison with similar health systems.

Researcher reflexivity

The researcher is a healthcare professional with prior clinical and academic experience within the Palestinian public health system. This insider status offered several advantages, including increased access, contextual sensitivity, and the ability to establish rapport with participants. However, it also introduced potential risks of interpretive bias, power asymmetry, and assumptions of shared understanding during interviews. To address these concerns, the researcher adopted a reflexive stance throughout the study. A structured interview guide with open-ended, neutral questions was used to minimize leading or directive questioning. The researcher maintained a reflexive journal to critically reflect on personal assumptions, emotional responses, and potential influence on data interpretation.

All interviews were conducted with an awareness of role-related dynamics and were followed by peer debriefing sessions with academic supervisors to challenge implicit bias and ensure fidelity to participants’ intended meanings. Furthermore, member checking with two participants helped validate early thematic interpretations, while independent review of coding by a secondary analyst contributed to analytic neutrality. These strategies collectively enhanced the study’s transparency and reproducibility by making the researcher’s position both explicit and methodologically accounted for.

Data analysis

Transcripts were subsequently analyzed using MAXQDA Analytics Pro Student Version 24.2.0. Thematic analysis followed the systematic framework of identifying meaning units, condensing them into core themes, and refining codes into subthemes and overarching categories. This iterative process was conducted collaboratively with the study supervisor to ensure rigor and alignment with qualitative research standards.

Results

This study investigated the perspectives of 13 nephrologists working in Palestinian hospitals across the West Bank, Palestine, on the feasibility and implementation of the NRRT model. The findings are organized into three primary categories: facilitators, barriers, and recommendations, each represented in Table 1 through corresponding key themes and descriptive insights. The table outlines five enabler themes that support the NRRT implementation, five barrier themes that hinder its adoption, and three strategic recommendation themes aimed at enhancing nephrology care and addressing AKI management in the Palestinian context.

Table 1.

Summary of key facilitators, barriers, and recommendations for NRRT implementation in Palestine

Category	Key themes	Description
Facilitators	MOH Strategic Policies	Robust government leadership, policy frameworks, and structured nephrology care integration.
Facilitators	Prevention-Driven Health System	Early detection, proactive health policies, and risk-based interventions to reduce AKI burden.
Facilitators	Multidisciplinary Collaboration & Nephrologist Early Engagement	Involvement of nephrologists,pharmacists, radiologist, nurses, and other specialists to ensure timely interventions.
Facilitators	Institutional Endorsement for Nephrology Care	Hospital-based monitoring systems, intake/output charting, and daily creatinine tracking for high-risk patients.
Facilitators	Advancing Technological Innovation	Implementation of AI-driven diagnostics, novel biomarkers (e.g., Cystatin C, NGAL), and electronic alert systems for early AKI detection.
Barriers	Systemic Governance and Policy Barriers	Lack of nephrology-specific policies, fragmented health governance, and insufficient regulatory frameworks.
Barriers	Financial and Operational Constraints	Limited funding, outdated dialysis machines, and poor infrastructure for nephrology services.
Barriers	Human Resource Insufficiency	Shortage of nephrologists, lack of residency programs, and migration of specialists due to low salaries.
Barriers	Prevention Strategies and Awareness Challenges	Poor health literacy, delayed nephrology consultations, and inadequate prevention efforts in primary care.
Barriers	Collaborations and Surveillance System Challenges	Lack of coordination among healthcare providers, absence of a national renal disease registry, and inconsistent patient tracking.
Recommendations	Policy and Governance Reforms	Strengthen nephrology policies, increase funding, implement national strategies, and establish a renal disease registry.
Recommendations	Capacity Building and Education	Expand residency programs, provide structured training for healthcare professionals, and enhance nephrology education.
Recommendations	Public Awareness and Prevention Strategies	Integrate prevention programs in primary care, establish nephrology-specific clinics, and enhance public education on kidney disease management.

Facilitators for NRRT implementation

Successful implementation of the NRRT model in Palestinian hospitals depends on several key enablers. Five facilitating themes were identified: MOH Strategic Policies, Prevention-Driven Health System, Multidisciplinary Collaboration and Nephrologist Early Engagement, Institutional Endorsement for Nephrology Care, and Advancing Technological Innovation (see Fig. 3). These themes reflect the structural, professional, and technological foundations essential for sustaining NRRT interventions and improving nephrology care.

Fig. 3.

Key facilitators to NRRT implementation in the Palestinian health system. This diagram illustrates five core enablers supporting the successful adoption of the nephrology rapid response team (NRRT) model

MOH strategic policies

A strong policy framework and effective leadership from the Ministry of Health (MOH) were consistently recognized as essential drivers for NRRT implementation. Nephrologists emphasized the pivotal role of the MOH in spearheading systemic reforms, ensuring sustainability, and fostering a coordinated approach to nephrology care. Leadership commitment was seen as a prerequisite for overcoming implementation barriers. One nephrologist highlighted this, stating:

“The Ministry of Health alone can establish this system.”. (Participant no. 8: 35)

In addition, centralized training workshops under MOH supervision were identified as a critical strategy for equipping healthcare providers with the necessary skills. Standardized training ensures uniform nephrology management practices across hospitals. Another participant elaborated:

“If you want to implement it, you need to coordinate and establish a center at the Ministry of Health where workshops are held in all hospitals for nurses and doctors.”. (Participant no. 4: 29)

Prevention-driven health system

Nephrologists advocated for integrating nephrology into a broader preventive health model, highlighting the importance of early detection, risk assessment, and proactive management of AKI. Shifting toward proactive policies is essential in reducing AKI incidence and its associated burdens. As one participant highlighted,

“If this system is implemented, it will have a great impact, and we will quickly see its benefits, particularly how effective AKI management reduces the duration of hospitalization, improves survival rates for many patients…”. (Participant no. 13: 27)

Primary healthcare was seen as a cornerstone of this strategy, particularly in facilitating early-stage CKD identification and long-term monitoring. Participants stressed the need for strengthened infrastructure, such as consistent follow-up protocols and regulated medication dispensing, to operationalize prevention. As one nephrologist explained, effective integration requires:

“They want to activate a preventive health system … patients with chronic kidney disease should have regular follow-ups and undergo basic tests consistently. Pharmacies should be prohibited from selling medications arbitrarily without a prescription”. (Participant no.11: 55)

Multidisciplinary collaboration & nephrologist early engagement

The role of multidisciplinary collaboration was another fundamental facilitator. Early involvement of nephrologists and interdisciplinary teamwork was considered essential for managing AKI. However, in the Palestinian healthcare context, early nephrologist consultations are often unavailable due to a shortage of nephrology specialists, a lack of structured referral systems, and an overburdened healthcare workforce.

Nephrology consultations are delayed or even overlooked due to the absence of nephrologists in certain regions. The heavy workload of the few available specialists limits their ability to provide timely consultations, often leading to late-stage referrals when patients require dialysis or critical care interventions. As one nephrologist remarked,

“Providing nephrology specialists is essential to manage AKI effectively, increasing recovery chances and preserving patients’ health. Residency programs are crucial” (Participant no. 4: 29).

Strengthening early multidisciplinary consultation was viewed as a low-cost, high-impact reform to improve AKI prognosis and reduce late-stage interventions.

Institutional endorsement for nephrology care

Institutional endorsement emerged as a significant enabler for implementing the NRRT model, particularly through the standardization of basic monitoring practices. Nephrologists consistently emphasized that simple, low-cost measures such as intake and output charting, regular patient weighing, and daily creatinine testing could serve as foundational tools for early detection and timely AKI management. One nephrologist illustrated this point:

” It is not difficult to take an intake and output chart for any patient. For high-risk patients or those on nephrotoxic medications, conducting daily creatinine lab tests is also simple. These practices do not require high costs, creativity, or significant effort.”. (Participant no. 3: 51)

These basic monitoring practices, though simple and low-cost, were viewed as foundational enablers of the NRRT implementation. When supported by institutional commitment and embedded into routine workflows, they offer a practical path toward early AKI detection and consistent, preventive nephrology care.

Innovation and technology integration: enabling early detection

Participants emphasized the need to integrate innovative, technology-driven tools to improve the early detection and management of kidney diseases. Two key innovations emerged: the use of novel biomarkers, particularly cystatin C, and the implementation of electronic alert systems. Cystatin C was recognized as a more sensitive indicator than creatinine, capable of detecting renal dysfunctions that traditional tests may miss. Likewise, electronic alert systems were identified as pivotal for the early identification and management of AKI.

As one nephrologist succinctly explained across different points in the interview:-

One of the most important biomarkers is cystatin C. It sometimes detects issues that creatinine cannot reveal … An automated alert system could ensure timely detection, prompting action before progression becomes irreversible, if integrated effectively with regulations. (Participant no. 1: 56)

In resource-constrained settings like Palestine, participants stressed that the successful implementation of these tools depends on a broader hospital strategy, including staff training, clearly defined clinical pathways, and strong regulatory oversight to ensure sustainability and impact. To avoid the risk of alarm fatigue, which can occur when alerts are excessive or poorly integrated, participants emphasized the importance of designing systems that prioritize clinical relevance and prompt appropriate action.

Barriers to NRRT implementation

The implementation of the NRRT model in Palestinian hospitals could face several systemic and operational barriers. These Obstacles span across governance (e.g., lack of policy coherence and weak leadership), financial constraints (e.g., insufficient funding for nephrology services), resource limitations (e.g., shortage of nephrologists and inadequate diagnostic tools), and awareness deficiencies (e.g., limited knowledge among healthcare providers and patients about AKI management). Five key themes summarizing these barriers are presented in Fig. 4, reflecting the complex interplay of structural and intermediary determinants within the healthcare system.

Fig. 4.

Key barriers to NRRT implementation in the Palestinian health system

Weak systemic governance and policy gaps

Structural weaknesses in health governance emerged as a central barrier to NRRT implementation. Nephrology care was described as fragmented, shaped by short-lived initiatives, reactive planning, and limited long-term investment. Participants repeatedly emphasized that Ministry of Health (MOH) programs often lacked continuity, leaving services exposed to shifting political agendas and financial shortfalls. One participant remarked,

“The Ministry of Health initiates programs, but unfortunately, they rarely complete them 100%”. (Participant no. 9:65)

This lack of sustainability reflects a broader governance dilemma in which nephrology remains marginalized, with no structured policies guiding decision-making or ensuring equitable service distribution.

Financial and operational constraints

Chronic underfunding and misallocated health budgets were cited as direct impediments to nephrology development. The frustration among participants was palpable, as they linked the dominance of reactive care (dialysis) to a lack of strategic investment in prevention, diagnostics, and early-stage interventions.

One nephrologist sharply criticized the Government of Palestine (GoP) for failing to allocate sufficient funds to the Ministry of Health (MOH), stating:

“They don’t allocate a proper budget for the Ministry of Health … With an adequate budget, we could conduct proper testing and avoid unnecessary dialysis procedures”. (Participant no. 11: 74–75)

Beyond infrastructure limitations, low salaries and overwhelming workloads are driving a wave of physician migration, further weakening the already fragile nephrology workforce. One nephrologist described the reality of Palestinian specialists leaving the country in search of better financial and professional stability:

“Some doctors go abroad and don’t return because the salary is 7,000 NIS (~$2,000), and they are overburdened with patients”. (Participant no. 13: 45–46)

The brain drain forms a real barrier to implementing structured, team-based models like our proposed NRRT. It deprives the system of the specialized workforce essential for coordinated and preventive nephrology care.

Nephrology workforce shortage

The implementation NRRT model in Palestinian hospitals is hindered by an acute shortage of nephrologists, an issue that has reached an unacceptable level. Dialysis centers often operate without specialist oversight, creating unsafe care environments and violating basic clinical standards. Participants highlighted a systemic failure to scale training programs alongside service expansion.

One participant vividly described this systemic gap:

“Dialysis centers opened … but where are the nephrology specialists? Ideally, there should be a plan to ensure every center has a specialist, but unfortunately, that’s not the case.”. (Participant no. 9: 24)

The absence of nephrologists in dialysis units is an abnormal and unacceptable condition, highlighting a dangerous disconnect between nephrology service expansion and workforce planning. Participants further noted that this workforce gap is compounded by the absence of a formal nephrology residency program and training opportunities in Palestine. Without addressing this imbalance, participants questioned how consistent and timely nephrology care could be delivered.

Weak prevention and public awareness

Participants criticized the underutilization of primary care centers for the early detection of kidney disease. Nephrology is typically addressed at advanced stages, with limited public education and provider training on the early detection of AKI risk. One nephrologist critically observed:

“In our context, … Patients are only referred to a nephrologist when they reach the stage of needing dialysis.”. (Participant no. 3: 29)

Beyond healthcare provider practices, misconceptions about kidney health among patients were also identified as barriers. Many individuals held simplistic or incorrect beliefs about kidney disease prevention, assuming that drinking more or less water alone could maintain kidney health. As one nephrologist noted:

“Some people think drinking too much or too little water affects kidney health, but that’s not true if the kidneys are functioning normally.”. (Participant no. 4: 29)

These gaps in awareness, limited emphasis on preventive care, and delays in nephrology referrals reflect ongoing challenges in integrating nephrology services within the broader healthcare system.

Collaborations and surveillance system challenges

A fundamental flaw in the current healthcare system, as revealed by participants, is the lack of coordination between primary and secondary healthcare services, fragmenting patient management and leading to disjointed care pathways. Patients often navigate a maze of healthcare providers—the Ministry of Health (MOH), military medical services, relief agencies, and UNRWA—each operating independently, without a centralized treatment plan or communication channel. One nephrologist reflected on this uncoordinated system:

“Healthcare services are being provided in multiple places, but there is no harmony or coordination between the primary healthcare centers.”. (Participant no. 10: 28)

This healthcare fragmentation creates delays in patient management, duplication of efforts, and inconsistent medication regimens. Patients receive conflicting prescriptions and undergo unnecessary duplicate tests due to the absence of a shared clinical record system.

Closely tied to this fragmentation is the absence of a national renal disease registry, which significantly limits strategic planning for kidney care. Without a centralized data repository, nephrologists lack critical tools for monitoring patient trajectories, assessing population-level burden, and informing clinical decision-making. One participant underscored this challenge:

… A proper registry system would help us follow patients better, especially as their numbers grow. Unfortunately, we don’t have any statistics at all. (Participant no. 7:40–41)

This data vacuum hinders evidence-based decision-making, making it impossible to allocate resources efficiently or develop national strategies for kidney disease management. The failure to establish a real-time surveillance system for CKD and AKI cases reflects a systemic oversight that continues to undermine nephrology services at every level.

Nephrologists’ insights: strategic recommendations for NRRT implementation

Grounded in their lived experiences and professional realities, nephrologists provided strategic recommendations to overcome the systemic barriers hindering the effective implementation of the NRRT model. Figure 5 illustrates and synthesizes the recommendations, which emerged organically from nephrologists’ daily experiences and direct engagement with the systemic challenges of the Palestinian healthcare system.

Fig. 5.

Key policy and system-level recommendations to strengthen nephrology care delivery in Palestine

Within the complex and resource-limited healthcare landscape, nephrologists articulated pragmatic solutions, highlighting the need for systemic transformation in nephrology care. Their recommendations consolidate into three interdependent themes, each addressing a critical aspect of health system reform.

The following section provides an in-depth exploration of these recommendations, capturing the nuanced perspectives and frontline realities of nephrologists as they reimagine nephrology care within a constrained yet resilient healthcare system.

Policy and governance reforms: a call for systemic change

Nephrologists consistently emphasized the need for comprehensive reforms in health governance to strengthen nephrology care. Their narratives revealed a fragmented system lacking strategic direction, sustainable funding, and cohesive referral mechanisms, factors that collectively undermine patient outcomes and limit the feasibility of NRRT implementation.

A central recommendation was the expansion of structured primary care services through the family medicine program. This was viewed as essential for shifting from dialysis-centered care toward early detection and prevention-based strategies. One participant articulated this vision through a more structured and patient-centered model:

“The Family Medicine program in Palestine needs to expand significantly and should serve as the first line of defense in managing such cases. These physicians are the ones who see patients first, refer them when necessary, and follow up on their conditions. This ensures a structured and coordinated approach to patient care.”. (Participant P. no. 9: 36)

Strengthening frontline care and referral coordination, alongside implementing a national nephrology strategy, was seen as foundational for enhancing system responsiveness and ensuring the long-term viability of nephrology reforms.

Capacity building and education: strengthening the foundations of nephrology care

A foundational recommendation was to strengthen the nephrology workforce through structured residency programs, continuous medical education, and general physician upskilling. Participants highlighted the need for both specialist and generalist training to improve early detection and AKI management. A nephrologist highlighted the dual necessity of medical training and a structured tracking system:

“General physicians must be trained on how to act as the first line of defense in managing kidney diseases. Additionally, there should be a kidney disease registry to ensure proper tracking and management of these cases.”. (Participant no. 9: 69)

This emphasis on education and capacity building reflects a deep awareness among nephrologists that closing the knowledge gap is pivotal to improving patient outcomes. Without a skilled and well-trained workforce, nephrology services will continue to struggle, leaving AKI and CKD patients vulnerable to mismanagement and late-stage referrals.

Participants envisioned a future where continuous medical education, structured residency programs, and a well-established nephrology registry would not just enhance individual skills but fortify the entire healthcare system, ensuring better patient care despite resource limitations.

Public awareness and prevention strategies: a shift toward proactive nephrology care

Nephrologists called for wide-scale public education and early intervention campaigns to reduce the rising burden of kidney disease. These would target both community misconceptions and systemic neglect in the early stages of care. A notable proposal was the creation of nephrology-specific outpatient clinics segmented by condition: CKD, AKI, and transplant to provide tailored treatment and improve follow-up. One participant articulated the necessity of this structured approach:

“Another important point is to have specialized clinics within government institutions: separate clinics for CKD and AKI. Managing chronic kidney disease is different from managing acute kidney injury because AKI patients have a good chance of kidney recovery. Therefore, in my opinion, nephrology services should be divided into three distinct clinics for optimal effectiveness—for kidney transplants, AKI, and CKD. (Participant no. 13: 17)

Integrating preventive nephrology into primary care and restructuring service models to reflect disease progression were seen as transformative strategies to improve long-term care and reduce dialysis dependency.

Discussion

This novel qualitative research provides a deeply contextualized epistemological lens, offering perspectives that quantitative metrics often fail to capture. Through the opinions of Palestinian nephrologists working within a resource-limited healthcare landscape, this study explores the complex interplay between systemic defects, technical barriers, and the potential for transformative nephrology care reforms in Palestine.

By exploring facilitators, barriers, and strategic recommendations, this qualitative analytical research goes beyond identifying challenges; it maps pathways for health reform, providing a locally grounded yet globally informed perspective on improving AKI management. The findings are consistent with international guidelines, such as KDIGO (Kidney Disease: Improving Global Outcomes). Rather than imposing a global standard, this research contextualizes these recommendations within the constraints, realities, and opportunities unique to the Palestinian healthcare system.

Nephrologists consistently asserted the MOH central role in leading systemic reforms to improve nephrology services. As the principal provider of nephrology care under the national health insurance framework, the MOH ensures free coverage for patients diagnosed with End-Stage Kidney Disease (ESKD). While this reflects commendable political will, participants highlight powerfully that embedding preventive strategies aimed at reducing the prevalence of CKD and AKI could significantly enhance the sustainability of health services and cost-effectiveness. The participants also recognize gaps in governance and policy implementation, noting that fragmented policies and the deprioritization of nephrology services undermine systemic efficiency. These observations align with previous research [7, 8], which confirms the need for cohesive national nephrology strategies to ensure long-term service stability.

From the nephrologists’ perspective, addressing these governance barriers requires a concerted effort by the MoH to institutionalize nephrology services within the broader public health framework. Strengthening governance structures through policy coherence, regulatory enforcement, and strategic resource allocation was seen as fundamental in fostering a more sustainable, prevention-driven nephrology model. Participants advocated for embedding standardized nephrology protocols within primary care, ensuring that early detection, risk assessment, and early referrals become vital components of the healthcare system rather than reactive responses.

A severe shortage of nephrology specialists in the West Bank and Gaza Strip presents a critical barrier to AKI and CKD management, significantly limiting timely intervention efforts. Alarmingly, only 13 board-certified nephrologists are responsible for overseeing nephrology care across the 16 cities in the West Bank, a figure grossly insufficient to meet the escalating burden of ESKD. This shortage is exacerbated by the reality that several hospitals operate hemodialysis units without a nephrologist, leaving general practitioners to manage complex renal cases without specialist oversight. The MOH Annual Health Report [3] underscores the need for workforce expansion and strategic intervention, as dialysis patient numbers have doubled from 1,014 in 2015 to 2,300 patients in 2025. Establishing nephrology residency programs, incentivizing specialization, and integrating structured nephrology training into general medical education were identified as critical facilitators to bridge the gap in nephrology expertise.

From a public health and policy view, addressing these workforce challenges demands systemic reforms that extend beyond hospital settings into primary healthcare facilities. These findings align with those Tam-Tham et al. [9], who similarly reported workforce shortages and collaboration gaps in CKD management within primary care. The NRRT model presents a viable mechanism for enhancing early multidisciplinary collaboration, ensuring that nephrologists are strategically allocated to high-risk cases while primary care physicians receive the necessary training to manage early-stage kidney disease. By prioritizing preventive nephrology services, strengthing early detection policies, and implementing structured workforce policies, the Palestinian healthcare system can antidoting the painful maximization in dialysis dependency while improving overall renal health outcomes.

Participants highlighted that inadequate MOH budgets and high out-of-pocket patient costs limit investments in critical infrastructure, workforce development, and diagnostic technologies. These financial barriers frequently slow down patients’ access to essential care, perpetuating inequities. Consistent with findings by Abdel-Kader et al. [10], tackling these financial barriers through strategic resource reallocation and health reforms is essential to ensuring sustainability and equity in nephrology care.

Beyond cost containment, which counts $ 50 million annually, a strong recommendation emerged for enhancing financial investments in preventive nephrology services. Addressing modifiable ESKD risk factors, such as diabetes and hypertension, through early screening, structured patient follow-up, and nephrology integration into primary care, could stop disease progression and reduce long-term dialysis demand. This prevention-based approach, such as the NRRT, is critical in ensuring a more cost-effective, sustainable, and equitable nephrology care.

The Palestinian health system remains heavily skewed towards curative care, consuming 75.5% of the total health budget, while preventive services receive a mere 1.5%. This disproportionate focus not only rising healthcare costs but also limits the sustainability of essential operational services. By reallocating resources and prioritizing preventive care initiatives, the Palestinian MOH can align its nephrology practices with global benchmarks, reinforcing its leadership in proactive healthcare delivery [11].

The investment in enhancing awareness among both healthcare providers and patients, alongside developing a countable responsiveness primary healthcare system, emerged as a milestone for addressing kidney health challenges. Participants highlighted significant deficits in knowledge and understanding of AKI and CKD. Many primary care providers lacked adequate training, leading to delays in diagnosis and treatment. Moreover, misconceptions about kidney health, such as reliance on hydration as a preventive measure, were common among patients, compounding these challenges. These findings align with Nash et al. [12] and Williams et al. [13], who emphasized the importance of educational programs to improve awareness and adherence to guidelines.

Further insights from Carpenter-Song et al. [14] offer a nuanced perspective on implementing AKI prevention strategies within interdisciplinary frameworks. They identified several systemic barriers to successful implementation, such as workflow disruptions, staff turnover, and limited leadership buy-in.

The NRRT model, if effectively implemented, presents a viable pathway for transforming AKI management, ensuring timely nephrology consultations, structured patient monitoring, and improved care coordination. However, its success depends on strong policy frameworks, financial restructuring, and the integration of multidisciplinary collaboration within the broader healthcare system.

By redirecting financial resources toward preventive nephrology services and enhancing primary care engagement, the Palestinian healthcare system can achieve greater sustainability, improved patient outcomes, and a more equitable distribution of nephrology resources. The findings of this study call for a strategic realignment of health policies that balances immediate patient needs with long-term nephrology care sustainability, ultimately fostering a resilient and prevention-driven healthcare model.

Transferability and relevance to global contexts

The findings of this study, while contextually grounded in Palestine, resonate with global nephrology care priorities, particularly in LMICs facing similar systemic challenges. As documented in the ISN–Global Kidney Health Atlas [15], global inequities in nephrology care persist, with severe shortages in nephrology specialists, limited funding, and inconsistent access to high-quality kidney replacement therapy (KRT). The Atlas emphasizes context-sensitive, preventive models—such as telemedicine, task-shifting, and team-based care—as essential for equitable nephrology advancement [15].

Kalyesubula et al. [16] similarly advocate for the integration of kidney care into broader health systems, emphasizing political will and scalable interventions. Mehta et al. [2], in the ISNs 0by25 Initiative, reinforce this by proposing health system integration, enhanced tracking, and point-of-care diagnostics to reduce preventable AKI deaths. The feasibility of such models is exemplified by Evans et al. [17], whose multicountry evaluation proved that low-cost AKI management using symptom-based risk scores and on-site diagnostics significantly improved early detection and outcomes.

Furthermore, Ravyn et al. [18] highlight facilitators such as institutional support and clinician education that directly strengthen NRRT viability, while Luyckx et al. [19] call for system-level reforms to close persistent knowledge-to-practice gaps. Together, these findings confirm the global relevance of locally generated strategies like NRRT, particularly for LMICs lacking robust infrastructure or universal coverage.

Collectively, these international perspectives enhance the contextual relevance and potential transferability of this study’s findings to other low-resource settings. Rather than endorsing a one-size-fits-all solution, they underscore the growing momentum in LMICs toward preventive nephrology strategies that emphasize early AKI detection and system integration. As reflected in participant narratives, timely intervention was viewed not simply as a clinical preference but as a practical and resource-sensitive response in environments where long-term dialysis remains financially and logistically constrained.

Conclusion

This study delves into the perspectives of nephrologists on the feasibility and implementation of the NRRT model in Palestinian governmental hospitals. Insights gathered align with the WHO Social Determinants of Health framework, emphasizing how structural determinants such as governance and resource allocation impact healthcare delivery. By incorporating the perspectives of practicing nephrologists, this research sheds light on systemic, operational, and resource-related challenges that hinder the optimization of health care services. The findings underscore the central role of the MOH in spearheading systemic reforms, with a focus on policy coherence, resource allocation, and fostering a preventive care paradigm. Proactive measures such as nephrologist-led interventions, primary care integration, and technology adoption emerged as key enablers for enhancing nephrology care, aligning with global guidelines like KDIGO.

Limitations

Despite the richness of insights, several limitations should be acknowledged. The qualitative nature of the research prioritizes depth over generalizability. Although the sample includes all board-certified nephrologists in the West Bank, it does not capture perspectives from the Gaza Strip, nor does it reflect the views of other stakeholders such as nurses, patients, policymakers, general practitioners, medical specialists, pharmacists, and other frontline healthcare providers.

Implications for future research

Future research should aim to triangulate findings through mixed-method approaches, incorporating quantitative data to strengthen the evidence base. Expanding the study scope to include multi-stakeholder perspectives and cross-regional comparisons can provide a more holistic understanding of nephrology care challenges and inform the design of comprehensive interventions. Addressing these limitations will not only enhance the robustness of future studies but also ensure that the insights generated effectively translate into actionable health policy reforms.

Bilal Jawabreh

is a doctoral researcher at the Faculty of Public Health, Al-Quds University, Jerusalem, Palestine, and a fellow with the Robert Koch Institute (RKI), GOARN, and the WHO Hub for Epidemic and Pandemic Intelligence in Berlin. With over 20 years of experience in public health, surveillance, and capacity building, his research focuses on nephrology, acute kidney injury management in low-resource settings, epidemic intelligence, and health system reforms. He is the corresponding author of this manuscript.

Author contributions

The authors conceptualized and designed the study, conducted interviews, analyzed the data, drafted the manuscript, and approved the final submission.

Funding

The study was self-funded.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available due to confidentiality agreements with participants, but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This qualitative study is part of a broader doctoral research thesis titled “Enhancing Acute Kidney Injury Management in Southern Palestinian Governmental Hospitals: Impact of Risk Triage, Novel Biomarkers, and Electronic Health Alerts,” which comprises three components: a quantitative study, a qualitative study, and a published systematic review (WCN25–3547, DOI: 10.1016/j.ekir.2024.11.184). Ethical approval for this specific qualitative component was obtained from the Institutional Review Board (IRB) at the School of Public Health, Al-Quds University (Approval No: 5/24, dated 13 February 2024), and from the Scientific Research Unit at the Palestinian Ministry of Health (Approval dated 28 February 2024). All participants were nephrology specialists who voluntarily agreed to participate. Informed consent was obtained before conducting any interviews. Participants were informed of the study’s objectives, procedures, and their right to withdraw at any point without penalty. Interviews were only conducted after verbal and written consent was secured. This study was conducted in accordance with the Declaration of Helsinki and adheres to the ethical principles of confidentiality, respect for persons, voluntary participation, and protection of participants’ rights, under national and institutional guidelines.

Consent for publication

Not applicable. This study does not include any identifiable personal data, images, or other information requiring individual consent for publication.

Competing interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.