BACKGROUND:
Kidney failure is a major non-communicable disease contributor to morbidity and mortality in low- and middle-income countries. Adequate hemodialysis is essential for survival and quality of life, yet evidence on hemodialysis adequacy and its determinants in sub-Saharan Africa remains limited. This study assessed the prevalence of optimal hemodialysis adequacy, explored healthcare workers’ perspectives, and identified associated factors at Kiruddu National Referral Hospital in Uganda.

METHODS:
A sequential explanatory mixed methods study was conducted among 122 adult patients receiving maintenance hemodialysis and eight purposively selected healthcare workers. Quantitative data were extracted from patient records and hemodialysis adequacy was assessed using the urea reduction ratio. Modified Poisson regression with robust standard errors was used to identify factors associated with optimal adequacy. Qualitative data were collected through in-depth interviews and analyzed using inductive content analysis.

RESULTS:
Only 48.4% of patients achieved optimal hemodialysis adequacy. Male sex, higher dialysate flow rates, and dialysis vintage of twelve months or longer were negatively associated with adequacy. In contrast, malnutrition and higher blood flow rates were positively associated. Healthcare workers identified key barriers to adequate dialysis, including financial constraints, poor adherence to treatment guidelines, inadequate staffing, frequent machine malfunction, and limited facility infrastructure.

CONCLUSIONS:
Less than half of patients with kidney failure in this public-sector setting received optimal hemodialysis, underscoring significant gaps in NCD care delivery. Both biological and health system factors influence dialysis adequacy, highlighting the need for policy interventions that strengthen financing mechanisms, standardize dialysis protocols, invest in infrastructure and workforce capacity, and improve governance of chronic kidney disease services in resource-limited settings.