|Year : 2020 | Volume
| Issue : 1 | Page : 39-44
Physicians' knowledge and practice with regard to acute kidney injury at Omdurman Military Hospital: A cross-sectional survey
Sulafa Mohamed Ali1, Safaa Badi2, Bashir Alsiddig Yousef3
1 Department of Clinical Pharmacy, Faculty of Pharmacy, University of Khartoum, Khartoum, Sudan
2 Department of Clinical Pharmacy, Faculty of Pharmacy, Omdurman Islamic University, Khartoum, Sudan
3 Department of Pharmacology, Faculty of Pharmacy, University of Khartoum, Khartoum, Sudan
|Date of Submission||27-Oct-2019|
|Date of Decision||31-Oct-2019|
|Date of Acceptance||05-Nov-2019|
|Date of Web Publication||13-Jan-2020|
Dr. Bashir Alsiddig Yousef
Department of Pharmacology, Faculty of Pharmacy, University of Khartoum, Al-Qasr Ave., Khartoum 11111
Source of Support: None, Conflict of Interest: None
INTRODUCTION: The fact that the incidence of acute kidney injury (AKI) is increasing globally, and that data from low- and middle-income countries are scarce and inadequate, necessitates that health-care professionals being knowledgeable and aware of all aspects of this underestimated disease. This study aimed to assess the knowledge and practice of physicians working in different specialties about AKI.
MATERIALS AND METHODS: This was a cross-sectional study; 169 physicians from Omdurman Military Hospital, practicing in different specialties, who were available at the time of the study, were included. Participants were assessed using a self-administered questionnaire. Data were analyzed using the Statistical Package for the Social Sciences.
RESULTS: The majority of the respondents were aged 29 years or less (74.1%), and 81.7% were female. Most of the respondents (63.9%) had <3 years of experience. About 62.1% of the samples were medical officers mainly from the department of emergency, internal medicine, and surgery. Nearly 56.8% of the participants were found to have moderate knowledge, whereas 23.7% had a good knowledge; there was a significant association between knowledge and professional level. Regarding AKI management practice, 56.6% of the respondents were found to have poor practice, whereas 5.7% found to conduct good practice. The practice was found to be not associated with years of experience, profession level, or specialty. There was a significant association between knowledge and practice scores (P < 0.001).
CONCLUSION: This study demonstrated knowledge and practice gaps as only one-fifth of the participants had a good knowledge and only 5% had a good practice.
Keywords: Acute kidney injury, knowledge, Omdurman Military Hospital, practice
|How to cite this article:|
Ali SM, Badi S, Yousef BA. Physicians' knowledge and practice with regard to acute kidney injury at Omdurman Military Hospital: A cross-sectional survey. Int J Health Allied Sci 2020;9:39-44
|How to cite this URL:|
Ali SM, Badi S, Yousef BA. Physicians' knowledge and practice with regard to acute kidney injury at Omdurman Military Hospital: A cross-sectional survey. Int J Health Allied Sci [serial online] 2020 [cited 2020 Mar 28];9:39-44. Available from: http://www.ijhas.in/text.asp?2020/9/1/39/275665
| Introduction|| |
A cute kidney injury (AKI) is defined as a rapid deterioration or loss of kidney functions that can be caused by a variety of different mechanisms., It is hoped that the adoption of an international definition for AKI by the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines will lead to improved recognition and earlier treatment of the disease, because AKI encompasses a wide spectrum of injuries to the kidneys, that is associated with poor patient outcomes. Epidemiologically, the incidence of AKI in high-income countries steadily increased., In 2013, a meta-analysis study included 4,9147,878 patients between 2004 and 2012, mainly in the hospital settings, that the pooled incidence of AKI was 22% in adults and 14% in children. Although 85% of the world's population lives in low- and middle-income countries, systematic prospective studies from those regions are limited; therefore, early detection is impaired by limited resources and poor understanding of the condition.
Lack of awareness about the impact of AKI on clinical outcomes and scarcity of supervision for nephrotoxin and polypharmacy exposure constitute important risk factors. Moreover, AKI can result in short- and long-term complications such as inpatient mortality, increased hospital stay, increased health costs, and long-term mortality. It is also associated with an increased risk of developing chronic kidney disease (CKD) along with accelerating the progression of preexisting CKD, end-stage renal disease, and death. Therefore, improving awareness of AKI in health-care organizations and residency training programs through case-based learning, workshops, or periodic grand rounds by a nephrologist will have a positive effect on the knowledge of health-care professionals., Furthermore, several studies showed a significant increase in awareness and practice satisfaction of doctors following an educational intervention program about AKI.,
This study is consequential, as the incidence of AKI in Sudan cannot be neglected. More notably, AKI is an important cause of morbidity and mortality in Sudan due to the high prevalence of many tropical diseases such as malaria, sepsis, and diarrheal diseases., Besides, uncertainty regarding the true incidence of AKI limits the awareness of the problem, thereby delay efforts to prevent its occurrence. This study aimed to assess the knowledge and practice of physicians working in Omdurman Military Hospital toward AKI.
| Materials and Methods|| |
This was a cross-sectional hospital-based survey that was conducted at Omdurman Military Hospital, Omdurman. The targeted population was physicians working in different specialties. The study was carried out from July to August 2018.
Inclusion and exclusion criteria
All physicians available at the time of the study who were willing to participate were included in the study, whereas those who refused to participate were excluded from the study.
Sample size and sampling method
A convenience sampling was used in this study, the samples were selected based on their availability throughout the data collection period, and the total sample size was 178 participants. The response rate was 95% (9 refused to participate in the study).
Data collection tool
Data were collected using a validated modified self-administered questionnaire which consists of three sections – Section 1: demographic data contain seven questions – age group, sex, years of experience, profession level, specialty, last degree, and training obtained; Section 2 about knowledge of AKI definition (1 question), knowledge of AKI risk factors (21 questions), and knowledge of nephrotoxic drugs (11 questions); and Section 3 about AKI management practice (7 questions). The questions were manually scored; each correct answer was given one point, and each incorrect and I don't know answer was given 0. Knowledge was considered poor if it was <50%, moderate if it was 50%–75%, and good if it was more than 75%. The same scale is done to assess practice.
The data were entered into the Statistical Package for Social Sciences version 23 software (IBM Corp., Armonk, NY). The results were presented in tabular form. The data were analyzed using descriptive statistics (frequency and percentages). The Chi-square test was applied to check the significant difference between categorical variables. P < 0.05 was considered significant.
The ethical clearance (FPEC-08-2018) was obtained from the Ethical Committee of the Faculty of Pharmacy, University of Khartoum. Informed consent was obtained from each participant. All questionnaires were coded with ensuring confidentiality throughout the study.
| Results|| |
A total of 169 physicians were recruited in the study from more than 15 different specialties. The majority of the respondents were aged 29 years or less (74.1%), and 81.7% were female. Most of the respondents (63.9%) had <3 years of experience and obtained their final degree and training nationally. About 62.1% of the samples were medical officers, 29.6% were registrars, and the rest were house officers and specialists. Among different specialties, 23.1% of the participants were in emergency medicine, 16% in internal medicine, 12.4% in surgery, and 11.2% in other specialties [Table 1].
There are several criteria for defining AKI, as shown in [Table 2]; the most commonly recognized definition by 44.3% was an increase in serum creatinine (SCr) to ≥1.5 times, which occurred within the prior 7 days. Almost 6.6% of the respondents reported that they do not know the AKI definition at all. From the total respondents, 4.1% identified the five definition criteria, whereas 62.1% of the respondents define only one criterion, which is an elevation in SCr to ≥1.5 times the baseline in the prior 7 days, and 11.2% identified three criteria.
The findings of physician knowledge about the conditions and drugs that can be associated with AKI showed that dehydration/volume depletion as an AKI risk factor was recognized by 97.6%, followed by sepsis (94.1%), nephrotoxic medications (92.3%), critical illness (89.9%), and poisons (89.3%). About 25.4% of the respondents did not consider chronic obstructive pulmonary disease as an AKI risk factor, followed by 18.9% for anemia and burns and 16% for liver cirrhosis. On the other hand, 23.7% of the respondents did not know whether major surgery is an AKI risk factor or not, followed by 10.7% for the radiocontrast agent, 9.5% for both history of AKI and heart failure, 7.1% for CKD, and 6% for hypertension. Regarding the knowledge about nephrotoxic drugs, the most recognized drugs were vancomycin (77.5%), nonsteroidal anti-inflammatory drugs (76%), and methotrexate (68.6%) [Table 3].
|Table 3: Knowledge toward the conditions and drugs that can be associated with acute kidney injury (n=169)|
Click here to view
After measuring the knowledge score, 56.8% of the respondents were found to have moderate knowledge, 23.7% have a good knowledge, and 19.5% have a poor knowledge. Using the Chi-square test, no significant association was found between knowledge and years of experience (P = 0.073) or specialty (P = 0.17). However, there was a significant correlation (P = 0.004) between knowledge and professional level. Forty percent of those who had a good knowledge were registrars, whereas only 2.5% of the house officers had a good knowledge.
Regarding the physician practice about AKI, 94% of the respondents reported that they face AKI cases in their practice, of which 42.8% said that it happens always and 3% said rarely. Seventy-two percent said that they do AKI risk assessment for their patients. Fifty-seven percent document AKI as past medical history and 80.8% call a nephrologist before the high-risk procedure or nephrotoxic drug administration [Table 4]. Regarding management of AKI, 56.9% of the respondents reported that they use international guidelines, whereas 11.8% said none. About two-thirds of the participants stated that their main source of information is medical literature [Table 4].
|Table 4: Practice toward acute kidney injury among the studied participants (n=169)|
Click here to view
Using scoring system, AKI management practice regarding risk assessment, nephrology consultation when necessary, and documentation of AKI was found to be inadequate, as just 5.7% of the respondents were found to conduct good practice, 37.7% were found to conduct inadequate practice, whereas 56.6% of the respondents' practice was found to be poor. The Chi-square test showed that there was no significant association between practices with years of experience (P = 0.212), and with profession level (P = 0.353), and with the specialty (P = 0.643). Interestingly, Pearson's correlational test showed that there was a highly significant correlation between knowledge score and practice score (correlation coefficient: 0. 35, P < 0.001)
| Discussion|| |
The results of this study confirmed that the knowledge level of the physicians regarding AKI definition, risk factors, and nephrotoxic drugs is insufficient. Although there are several criteria for AKI adopted by different guidelines, just 4.1% figured out all the diagnostic criteria. The absence of local guidelines for AKI management may have a great contribution to the diversity of techniques when suspecting or dealing with AKI. Moreover, the management will entirely depend on personal practice or available resources. AKI is defined by KDIGO based on the SCr, either as an elevation in SCr by ≥0.3 mg/dl within 48 h, or an elevation in SCr to ≥1.5 times baseline, which is occurred within the prior 7 days, or urine volume <0.5 ml/kg/h for 6 h. Unfortunately, this definition is somehow recent, and there has been no uniformly accepted definition of AKI for a long time. Studies used different criteria to define AKI, including SCr or blood urea nitrogen changes or the need for dialysis.
Although hypertension, diabetes mellitus, cardiovascular diseases, CKD, and old age were the most common risk factors for the development of AKI, volume depletion and sepsis were the most recognized AKI risk factors in Sudan. Similarly, poor recognition of AKI risk factors has further been identified more recently in the National Confidential Enquiry into Perioperative Deaths study. About 60% of hospital-acquired AKI can be accounted for by drug-induced nephrotoxicity, which is the main cause of mortality and morbidity. Among these nephrotoxic drugs, aminoglycosides were shown the most common ones to cause renal insufficiency. In a current study, at least 12 drugs were implicated, participants showed variation between respondents in knowledge to the association of these drugs and AKI development. This finding is similar to that reported by Adejumo et al. who noted a poor knowledge regarding nephrotoxic drugs. This result may be attributable to deficiencies in undergraduate teaching, postgraduate training, or the need for continuous medical education on drugs that can induce AKI to raise the awareness among physicians.
Almost every physician (94%) encounters AKI in their daily practice, and 72% of them undergo patient risk assessment for AKI. The presence of risk factors on risk assessment should always alert the attending physician toward the importance of monitoring the kidney function once patients are admitted and throughout their hospital stay; such an intervention is expected to allow for early detection of the AKI and decrease its morbidity and mortality., After the first medical visit, clinicians determine the risks of AKI and need to reevaluate these risks in case of new exposures to other factors such as nephrotoxins, surgery, and sepsis. This study revealed that knowledge regarding AKI is associated with professional level (P = 0.004) and not significantly associated with years of experience (P = 0.073). Contrary, in another study, aimed to assess the baseline knowledge of clinicians in dealing with patients with AKI, in which they found the knowledge regarding AKI is not associated with experience of the clinicians. In addition, in another study, a significantly higher percentage of more experienced respondents were able to identify AKI risk factors and most AKI-causing drugs.
AKI management practice, in terms of patient risk assessment, consultation of nephrologist before high-risk procedure or administration of nephrotoxic medication, and documentation of AKI as past medical history, is not associated with either year of experience, and professional level, or with physician specialty. This was unanticipated because more years of experience mean a higher probability of being exposed to AKI cases, especially in personnel whose line is nephrology or urology. In a similar study conducted by Alabdan et al., more experienced respondents were more likely to report that they perform AKI risk assessment and stratification, while the physician professional level had no measurable effect on AKI management. The highly significant association between knowledge and practice was revealed by this study (P = 0.000); this sounds logical as the more the physician was aware and equipped with knowledge and tools to identify the disease, the better his conducted practice will be. Applying of educational intervention program can lead to increase the practice satisfaction of doctors in the diagnosis of AKI, such as a study done in the UK, in which practice satisfaction increased from 50% to 68% following intervention program.
The limitations of the current study are that the cross-sectional design may not allow for the temporal relationship for the outcome and other factors. In addition, the study may not represent all physicians within the hospital. Despite these limitations, the study is novel, and its finding reflects the first report about the knowledge and the practice of physicians toward AKI in this hospital. The study has also been able to determine the knowledge and practice gaps in AKI, which provide the areas that need interventional educational programs abled to improve AKI diagnosis and management.
| Conclusion|| |
This study demonstrated knowledge and practice gaps as only one-fifth of the participants had a good knowledge and only 5% had a good practice. The knowledge was found to be associated with professional level. The practice was found to be associated with knowledge. Further studies are needed to assess physicians' practice and to explain how it is affected by different factors. Incorporation of various educational programs on AKI to doctors may improve their knowledge and practice for the prevention of AKI and proper diagnosis and management of AKI.
Financial support and sponsorship
This study was financially supported by the Faculty of Pharmacy, University of Khartoum, and Faculty of Pharmacy, Sudan International University, Sudan.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Evans R, Rudd P, Hemmila U, Dobbie H, Dreyer G. Deficiencies in education and experience in the management of acute kidney injury among Malawian healthcare workers. Malawi Med J 2015;27:101-3.
Kellum JA, Lameire N, Aspelin P, Barsoum RS, Burdmann EA, Goldstein SL, et al
. Kidney disease: Improving global outcomes (KDIGO) acute kidney injury work group. KDIGO clinical practice guideline for acute kidney injury. Kidney International Supplements 2012;2:1-138.
Ali MN, Lewington AJ. Invited manuscript poster on renal-related education American Society of Nephrology, Nov 16-21, 2010. Do medical trainees receive adequate training in the management of acute kidney injury? Ren Fail 2011;33:669-71.
Lewington AJ, Cerdá J, Mehta RL. Raising awareness of acute kidney injury: A global perspective of a silent killer. Kidney Int 2013;84:457-67.
Lameire NH, Bagga A, Cruz D, De Maeseneer J, Endre Z, Kellum JA, et al.
Acute kidney injury: An increasing global concern. Lancet 2013;382:170-9.
Mehta RL, Cerdá J, Burdmann EA, Tonelli M, García-García G, Jha V, et al.
International society of nephrology's 0by25 initiative for acute kidney injury (zero preventable deaths by 2025): A human rights case for nephrology. Lancet 2015;385:2616-43.
Susantitaphong P, Cruz DN, Cerda J, Abulfaraj M, Alqahtani F, Koulouridis I, et al.
World incidence of AKI: A meta-analysis. Clin J Am Soc Nephrol 2013;8:1482-93.
Cerdá J, Mohan S, Garcia-Garcia G, Jha V, Samavedam S, Gowrishankar S, et al.
Acute kidney injury recognition in low- and middle-income countries. Kidney Int Rep 2017;2:530-43.
Alabdan N, Elfadol AH, Bustami R, Al-Rajhi YA, Al-Sayyari AA. Awareness of acute kidney injury risk factors and perspectives on its practice guidelines. Hosp Pract (1995) 2018;46:137-43.
Doyle JF, Forni LG. Acute kidney injury: Short-term and long-term effects. Crit Care 2016;20:188.
Akbar SR, Iqbal HI, Ahmed U. The need to emphasize nephrology knowledge in residents-in-training. N
Am J Med Sci 2015;7:524-8.
Xu G, Baines R, Westacott R, Selby N, Carr S. An educational approach to improve outcomes in acute kidney injury (AKI): Report of a quality improvement project. BMJ Open 2014;4:e004388.
James MT, Dixon E, Roberts DJ, Barry R, Balint C, Bharwani A, et al.
Improving prevention, early recognition and management of acute kidney injury after major surgery: Results of a planning meeting with multidisciplinary stakeholders. Can J Kidney Health Dis 2014;1:20.
Abdelraheem M, Ali el-T, Osman R, Ellidir R, Bushara A, Hussein R, et al.
Outcome of acute kidney injury in sudanese children – An experience from a Sub-Saharan african unit. Perit Dial Int 2014;34:526-33.
Osman M, Shigidi M, Ahmed H, Abdelrahman I, Karrar W, Elhassan E, et al.
Pattern and outcome of acute kidney injury among Sudanese adults admitted to a tertiary level hospital: A retrospective cohort study. Pan Afr Med J 2017;28:90.
Section 2: AKI definition. Kidney Int Suppl (2011) 2012;2:19-36.
Mehta RL, Kellum JA, Shah SV, Molitoris BA, Ronco C, Warnock DG, et al.
Acute kidney injury network: Report of an initiative to improve outcomes in acute kidney injury. Crit Care 2007;11:R31.
Cartin-Ceba R, Kashiouris M, Plataki M, Kor DJ, Gajic O, Casey ET. Risk factors for development of acute kidney injury in critically ill patients: A systematic review and meta-analysis of observational studies. Crit Care Res Pract 2012;2012:691013.
Lunn JN. The national confidential enquiry into perioperative deaths. J Clin Monit 1994;10:426-8.
Dashti-Khavidaki S, Shahbazi F, Khalili H, Lessan-Pezeshki M. Potential renoprotective effects of silymarin against nephrotoxic drugs: A review of literature. J Pharm Pharm Sci 2012;15:112-23.
Mingeot-Leclercq MP, Tulkens PM. Aminoglycosides: Nephrotoxicity. Antimicrob Agents Chemother 1999;43:1003-12.
Adejumo O, Akinbodewa A, Alli O, Olufemi P, Olatunji A. Assessment of knowledge of acute kidney injury among non-nephrology doctors in two government hospitals in Ondo city, Southwest, Nigeria. Ethiop J Health Sci 2017;27:147-54.
Sykes L, Nipah R, Kalra P, Green D. A narrative review of the impact of interventions in acute kidney injury. J Nephrol 2018;31:523-35.
Kashani K, Macedo E, Burdmann EA, Hooi LS, Khullar D, Bagga A, et al.
Acute kidney injury risk assessment: Differences and similarities between resource-limited and resource-rich countries. Kidney Int Rep 2017;2:519-29.
[Table 1], [Table 2], [Table 3], [Table 4]