Overcoming barriers to maintain hemodialysis adequacy amongst hemodialysis patients in hospital: a best practice implementation project.

OBJECTIVE: The aim of this evidence implementation project was to identify the barriers and omissions affecting adequacy of hemodialysis and to develop implementable strategies to maintain hemodialysis adequacy among hemodialysis patients with end-stage renal disease. INTRODUCTION: Assessing adequacy of hemodialysis and improving quality of life are important issues for patients with end-stage renal disease. However, they are often inadequately addressed, and evidence-based practices are not always followed. METHODS: A clinical audit was undertaken using the Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice approaches. Seven audit criteria that represent best practice recommendations for maintaining hemodialysis adequacy among hemodialysis patients were used. A baseline audit was performed, which was followed by the implementation of multiple improvement strategies over 20 weeks and the outcomes finalized using a follow-up audit to determine the change to be implemented in practice. RESULTS: The baseline audit results showed that most audit criteria were less than 77% in practice. The compliance rates for nurses who had received education regarding hemodialysis, checking the prescription order for each patient at each session, and using the prescribed dialyzer for every session were determined to have reached 100% at the follow-up audit. The compliance rates for completion prehemodialysis checks, using a sterile technique when inserting an arteriovenous catheter, matching a blood flow rate with the prescription, and maintaining a blood flow rate throughout the treatment session were found to be 73-95% at the follow-up audit. The most significant finding was the proportion of hemodialysis patients with inadequate urea reduction ratio was reduced from 4.6 to 3.2% after implementation of the best practice approaches. CONCLUSION: The implementation of institution-specific evidence-based resources brought about immediate improvements in hemodialysis adequacy management and practice. A variety of strategies contributed to the success of this implementation project, such as scenario simulation education, Objective Structured Clinical Examination, the interrelation response system Kahoot, the use of hemodialysis International Organization for Standardization job descriptions, regular weekly audits, and collaboration with physicians when caring for patients during clinical practice.

The roles of carboxylesterase and CYP isozymes on the in vitro metabolism of T-2 toxin.

BACKGROUND: T-2 toxin poses a great threat to human health because it has the highest toxicity of the currently known trichothecene mycotoxins. To understand the in vivo toxicity and transformation mechanism of T-2 toxin, we investigated the role of one kind of principal phase I drug-metabolizing enzymes (cytochrome P450 [CYP450] enzymes) on the metabolism of T-2 toxin, which are crucial to the metabolism of endogenous substances and xenobiotics. We also investigated carboxylesterase, which also plays an important role in the metabolism of toxic substances. METHODS: A chemical inhibition method and a recombinant method were employed to investigate the metabolism of the T-2 toxin by the CYP450 enzymes, and a chemical inhibition method was used to study carboxylesterase metabolism. Samples incubated with human liver microsomes were analyzed by high performance liquid chromatography-triple quadrupole mass spectrometry (HPLC- QqQ MS) after a simple pretreatment. RESULTS: In the presence of a carboxylesterase inhibitor, only 20 % T-2 toxin was metabolized. When CYP enzyme inhibitors and a carboxylesterase inhibitor were both present, only 3 % of the T-2 toxin was metabolized. The contributions of the CYP450 enzyme family to T-2 toxin metabolism followed the descending order CYP3A4, CYP2E1, CYP1A2, CYP2B6 or CYP2D6 or CYP2C19. CONCLUSION: Carboxylesterase and CYP450 enzymes are of great importance in T-2 toxin metabolism, in which carboxylesterase is predominant and CYP450 has a subordinate role. CYP3A4 is the principal member of the CYP450 enzyme family responsible for T-2 toxin metabolism. The primary metabolite produced by carboxylesterase is HT-2, and the main metabolite produced by CYP 3A4 is 3'-OH T-2. The different metabolites show different toxicities. Our results will provide useful data concerning the toxic mechanism, the safety evaluation, and the health risk assessment of T-2 toxin.