Considerations of implementation science in resource-limited settings

Closing the know-do gap in critical care nephrology requires delivery models that fit context, foreground equity, and sustain results in resource-limited settings (RLS). This narrative review proposes a pragmatic, equity-first roadmap to implement blood purification and kidney-saving practices in RLS by integrating CFIR for context diagnosis, RE-AIM for planning and evaluation, and ERIC for strategy selection, aligned with implementation outcomes (acceptability, feasibility, fidelity, cost, penetration, sustainability). We reconceptualize "resources" as a design variable, introducing a Resource Readiness domain spanning workforce, power/connectivity, supply chains, maintenance, and data systems. We outline learning-while-doing methods: hybrid effectiveness-implementation designs, PDSA cycles, audit-and-feedback, and community co-design to enable adaptive delivery without eroding core functions. Illustrative applications map RE-AIM actions for adoption (e.g., ultrasound-guided dialysis catheter placement, AKI recognition bundles) and de-implementation (e.g., low-value prophylaxis), emphasizing task-sharing, simplified workflows, offline-tolerant tools, and equity guardrails (pre-specified subgroups, access supports, equity-stratified reporting). The adapted CFIR figure depicts how system, site, workforce, and community layers shape mechanisms and outcomes across implementation, clinical, and equity domains. We propose practical recommendations for implementers, funders, and journals to require transparent reporting of context, adaptations, costs, and governance, and to invest in durable local capacity and shared stewardship. An equity-first, resource-aware pathway can accelerate uptake, fidelity, and sustainability of evidence-based kidney care in RLS.