Knowledge, Attitude and Practice Regarding Kidney Diseases among Primary Care Physicians working in Nepal

Methods: This was a descriptive, cross sectional, questionnaire based study, conducted over the span of 12 weeks among the primary care physicians. The Ethical Review Board of Nepal Health Research Council had approved our protocol prior to starting the study (Reference number: 2807). An arbitrary scoring system was used to classify knowledge, attitude and practice scores as: 0 to <50% Poor score, 50% to <75% Moderate score, ≥ 75% Good score. Data was entered in Microsoft Excel and analyzed using IBM Statistical Package for the Social Sciences version 25.

We have very limited studies regarding knowledge, attitude and practice (KAP) on kidney diseases from Nepal. Medical officers and residents doctors in teaching institutes are the first contact primary care physicians (PCPs) in most of the health care facilities in Nepal. We intend to study knowledge, attitude and practice regarding kidney diseases among these PCPs, working as the first contact health care providers, at different health institutes all over the country.

Methods
This cross-sectional study was conducted over the span of 12 weeks from 1st September, 2020 till 31st November, 2020. The study protocol was approved by the Ethical Review Board of Nepal Health Research Council (Reference number: 2807) prior to the start of data collection. Convenient sampling was done and data was collected through an online questionnaire, which was circulated to primary care physicians that chiefly included medical officers and resident doctors, working in different health institutes, all over Nepal. PCPs with less than six months of work experience were excluded from the study. The nephrology specialists and those who had already obtained post graduate degree in any other specialty were also excluded from the study.
All PCPs needed to answer a yes-no question before proceeding to the questionnaire to confirm their voluntary participation. After confirmation, they were directed to a questionnaire which consisted of four sections: first section had demography related questions, second section had eleven questions related to knowledge, third section had five questions related to attitude and fourth section had ten questions related to practice regarding kidney diseases. In our KAP survey questionnaire, the knowledge section consisted of questions on the updated definitions, stages and risk factors of acute and chronic kidney disease. It also had questions on nephrotoxic drugs, high and low potassium-containing foods, emergency indications for dialysis and treatment of hyperkalemia. Attitude section consisted of questions to assess promptness of primary care physicians to seek specialized care for kidney disease patients. Questions in practice section were devised to analyze the behavior of physicians for dietary counseling, measurement of urine output and weight of kidney disease patients, preservation of non-dominant arm in patients of end stage renal disease and tendency to calculate estimated glomerular filtration rate (eGFR) rather than only relying on serum creatinine to assess kidney function in a patient (Appendix 1).
Each correct answer in knowledge section and safe practice was scored 1 point. Correct answers in knowledge and practice section were assigned as per current standard guidelines. Multiple correct answers in a question got points for each correct answer. Incorrect answer/ unsafe practice/ I don't know was scored 0 point. Scoring in the attitude section was done as per Likert scale from 1 to 5. Maximum scores that could be obtained for knowledge, attitude and practice were 37, 24 and 8 respectively. An arbitrary scoring system was used to classify knowledge, attitude and practice scores as: 0 to <50% -Poor score, 50% to <75% -Moderate score, 75% and above -Good score. Attitude score of <50% was regarded as negative attitude and score of more than or equal to 50% was regarded as positive attitude.
Pretesting was done with first 50 responses of the primary care physicians. Cronbach's alpha was calculated for the reliability analysis of our study questionnaire during pretesting. The value was calculated as 0.724 after which only the questionnaire was circulated to rest of the study population.
Total number of medical officers registered under Nepal Medical Council till 31st July, 2020 was 18588. 7 The formula used for calculation of sample size in our study was: Sample size (N) = Where z score = 1.96 at 95% confidence interval, p = standard deviation, e = margin of error, n = population size (taken as 18588).
With 95% confidence interval, 50% standard deviation and 7% margin of error, calculated sample size for our KAP study was at least 194. SPSS IBM version 25.0 was used for analysis. Descriptive statistics were presented using means and standard deviation for continuous variables, and frequencies and percentages for categorical variables.

Results
The study enrolled 239 primary care physicians which included 198 medical officers and 41 resident doctors working in different health institutions all over Nepal. 209 (87.5%) participants were less than 30 years of age. 172 (72%) had work experience of more than one year and 108 (42.5%) PCPs were working in province three of Nepal. 61 (25.5%) PCPs were working in province level hospitals, 70 (20.9%) in primary level hospitals, 35 (14.6%) in autonomous institutions and 21 (12.1%) were working in private hospitals. 94 (39.3%) doctors were working in centers with dialysis facilities, 81 (34%) were working in health institutes with a dedicated nephrology unit/nephrologist and 116 (48.5%) had experience of working in centers with nephrology facilities in the past ( Table 1).
Regarding the definition of acute kidney injury, decrease in urine output to less than 0.5 ml/hour for more than six hours was the most common AKI criteria identified by 170 (79.5%) study participants, whereas only 107 (44.5%) PCPs identified increase in serum creatinine by 0.3 mg/dl within 48 hours to be the criteria for AKI. 164 (68.6%) doctors correctly responded as three months to be the duration of functional kidney damage for diagnosis of chronic kidney disease. 216 (90.4%) study participants correctly identified the number of stages of CKD to be five (Table 4).
JAIM 21 (Volume 11 | Number 1 | January-June 2022) Around 205 (85.8%) PCPs responded that they attend to cases of kidney diseases in their daily practice. Only 104 (43.6%) doctors responded that kidney diseases were adequately managed in their medical practice. 26 (10.9%) participants responded that they had received no training at all and 119 (49.8%) responded that they had received some training during their under-graduation program to identify kidney diseases and provide basic/emergency management to such patients. 186 (77.8%) PCPs responded that it was possible to have kidney disease despite normal creatinine. However, only 107 (44.8%) doctors calculated estimated glomerular filtration rate (eGFR) in elderly patients with normal serum creatinine while prescribing antibiotics. The formula most commonly used by the study participants to calculate eGFR was Cockroft-Gault formula (66.1%) followed by Modification of Diet in Renal Disease equation (19.7%) and Chronic Kidney Disease-Epidemiology Collaboration equation (14.2%) (Appendix 1).

Discussion
Nephrology was known to be the disregarded specialty in clinical medicine. 8 History of nephrology services in Nepal dates to just four decades back. 9 Nephrology services in Nepal, for the diagnosis and treatment of kidney diseases, has been recently prioritized in health-related national agendas. With the exponential rise of kidney diseases in South Asia, providing specialized comprehensive care to patients of kidney disease is a challenge.10 In such a scenario, most of the patients of renal disease are attended by non-nephrology doctors.
International Society of Nephrology (ISN) had launched 0 by 25 campaign in the year 2013 with the goal to have no deaths from preventable or untreated AKI in low resource settings by 2025 A.D. 11 This necessitates early identification of AKI, avoidance of further insults and aggressive management of AKI in community settings, which requires first contact health care providers and PCPs to play active roles. Assessing knowledge, attitude and behaviors of these primary care physicians regarding kidney diseases is of utmost importance in order to identify areas of deficiencies that need to be emphasized when organizing educational programs to improve patient outcomes.
Our study showed that 198 (83%) PCPs enrolled in our survey had obtained moderate to poor knowledge scores. Only 41 (17%) doctors obtained good knowledge scores ( Figure 1). These findings are somewhat similar to a study by Anees et al from Pakistan where only 18.4% non-nephrology doctors had good knowledge. 5 Another study by Ali et al from Sudan reported only 23.7% medical officers had good knowledge regarding kidney diseases. 12 None of the study participants in our study had negative attitude to kidney diseases. Likewise 198 (83%) PCPs had obtained good practice scores in our study (Figure 1). This finding was in contrast to the findings by Ali et al where 56.6% non-nephrology doctors had poor practice regarding kidney diseases. 12 Majority of the doctors in our study had good practice scores. This was a rewarding finding in our study as most of the enrolled physicians were young Nepalese doctors, practicing in both rural and urban settings, from primary to tertiary level health institute. Majority of respondents obtained good practice scores in contrast to moderate to poor knowledge scores; this could be explained with the type of questions set in the knowledge and practice section (Appendix 1). Knowledge section consisted of questions on the updated definitions, renal diet, nephrotoxic drugs, and major risk factors for AKI; however practice questions mainly dealt with basic practice behaviors to be followed while examining a patient with renal dysfunction. Emphasis on diet, urine output, weight and fluid balance of the patient, calculation of estimated glomerular filtration rate, ordering a urine routine examination to search for active urinary sediments and preservation of nondominant arm in an ESRD patient are basic behavioral skills that a physician need to master while approaching a patient of kidney disease. Implementing these simple yet vital practices would eventually assist doctors for early diagnosis and better management of nephrology patients. Most of the primary care physicians enrolled in our study had acknowledged these correct practices and behaviors.
Only 109 (45.6%) doctors identified chronic liver disease (CLD) and 125 (52.3%) doctors identified elderlies as the risk factors of acute kidney injury ( Table 3). Prevalence of AKI ranges from 20 to 50% among hospitalized patients with cirrhosis. 13 Similarly, elderlies are prone to develop AKI due to kidney senility, presence of comorbidities and medical interventions like surgeries, drugs and use of contrasts. 14 Primary care physicians need to strongly consider elderlies and CLD as a risk factor of AKI and try to avoid any nephrotoxic practices that would increase risk of kidney damage in such group of patients. It is imperative that kidney function must be assessed with eGFR in such groups of patients to identify subclinical kidney dysfunction and avoid renal insults as much as possible.
Aminoglycosides (Gentamicin) and non-steroidal antiinflammatory drugs (NSAIDS-Ibuprofen) were the most commonly identified groups of nephrotoxic drugs in our study (Table 3). Furosemide, a loop diuretic, was identified as a nephrotoxic drug by less than one third of total respondents (Table 3). A multi-centric study in Shanghai reported diuretics to be the cause of 22.2% of all drug-induced AKI, ranked only after antibiotics. 15 It is necessary to train medical doctors to acknowledge nephrotoxic effect of loop diuretics and individualize diuretic dose in every patient depending on volume status of the patient. Similarly, pantoprazole, a proton pump inhibitor (PPI), is another drug whose nephrotoxic potential was identified by only 68 (28%) respondents in our study (Table 3). Acute interstitial nephritis related to use of pantoprazole was first reported in 2004 A.D and since then this complication is increasingly being recognized worldwide. 16 It is necessary that PCPs need to have high degree of clinical suspicion in cases of unexplained renal failure ensuing few weeks to months of starting PPIs so that offending drug could be discontinued early to ensure favorable outcome in terms of renal recovery. Amlodipine, amoxicillin and azithromycin were misidentified as nephrotoxic medication by some PCPs in our study. Except for some rare case reports of interstitial nephritis induced by amoxicillin and azithromycin, these drugs are considered to be relatively safer for use in patients with renal impairment.
Hyperkalemia has been linked to cardiotoxicity and increases the odds of mortality within one day of the event in patients of CKD. 17 Current recommendations are to limit the potassium intake to less than 2000mg to 3000mg per day in CKD patients with eGFR of <30-60 ml/min/m 2 . 18 Low doctor-patient ratio and lack of knowledge among treating physicians often lead to inadequate dietary counseling to patients of kidney diseases. Unable to understand the implications of renal diet, patients suffer from unnecessary pill burden to manage hyperkalemia, financial loss, adverse events, and even premature deaths. Around 227 (95%) PCPs in our study correctly identified bananas as high potassium-containing food. However, oranges, tomatoes, chocolates, nuts and legumes, milk and milk products were JAIM 21 (Volume 11 | Number 1 | January-June 2022) identified as high potassium-containing foods by less than one half of the total respondents in our study. Apples, eggs, white meat products like chicken are low potassium-containing foods which were misidentified as having high potassium content by some doctors in our study (Table 3).
Major milestones in the field of nephrology in Nepal were the introduction of sub-specialty post-graduation nephrology programs a decade back, provision of extended government support to end stage renal disease patients with 'Free dialysis to all' program in 2016 A.D and the kidney transplant program that started in 2008 A.D. 19 With achievement of these milestones, undergraduate teaching has recently started focusing on nephrology as an indispensable specialty. However, 145 (60.7%) primary care physicians in our study responded that they had received no training at all or had only received some training during their undergraduate course for diagnosis and basic/ emergency management of kidney disease patients (Appendix 1). Focused and practical educational curriculum and subspecialty clinical rotations during undergraduate teaching should be promoted to improve knowledge regarding kidney diseases among PCPs. Targeted trainings and practice sessions must be organized at community level for these first contact health care providers for improving knowledge and practices related to management of kidney diseases. With the rising number of kidney disease patients outnumbering the number of nephrologists in current scenario, PCPs who have reached every nook and cranny of this country, could play a critical role to integrate basic nephrology services as part of primary patient care. Thus, it is high time that all stakeholders need to plan and execute programs for improving knowledge, attitude and practice of primary care physicians for better management of patients with renal dysfunction.
The main limitation of our KAP study was that it was based on a self-reported questionnaire, which may be susceptible for self-presentation bias. The study included heterogeneous group of primary care physicians working in different levels of health institute and from different provinces of Nepal. Thus, it is difficult to generalize our results to all of the primary care physicians working in Nepal.

Conclusions
To conclude, primary care physicians are the first contact health care providers in most of the health institutes of rural and urban Nepal. Our study demonstrated that the majority of primary care physicians in our study had moderate to poor knowledge scores but a positive attitude and had good practice scores regarding kidney diseases.