OBJECTIVES

Clinical pathways (CPs) ensure adherence to heart failure (HF) management guidelines. To optimize quality care in a low resource setting, an evidence-based care pathway for the management of acute HF was implemented at the emergency department (ED) of the Philippine General Hospital (PGH), the designated national tertiary hospital and referral center. This study aimed to describe the characteristics of adults with acute HF admitted at the ED and evaluate the quality of care they received, measured using physician adherence to the hospital’s acute heart failure CP.

METHODS

This was a retrospective, descriptive cohort study. We reviewed the inpatient charts of all adult patients with acute HF admitted to the ED of the PGH and referred to the Division of Cardiovascular Medicine between December 1, 2022 and May 31, 2023. Quality of care was assessed based on adherence to quality indicators adapted from routine and conditional order sets detailed in the pathway. Descriptive statistics was utilized to describe patient characteristics, quality of care, and outcomes.

RESULTS

Two hundred thirty-six (236) patients were included, with a mean age of 51.8 years. Majority were male (53.4%); hypertension (61.4%) and ischemic heart disease (53.8%) were the most common comorbidities, and infection the most common precipitant of decompensation (60.6%). There were optimal adherence rates to routine orders, which included referrals to Internal Medicine and Cardiology, baseline vital signs monitoring, fluid intake and output monitoring, chest radiograph, complete blood count, blood urea nitrogen, sodium, potassium, prothrombin time, partial thromboplastin time, arterial blood gas, urinalysis, and N-terminal pro b-type natriuretic peptide. Conditional orders, such as oxygen support, focused echocardiography, thyroid - stimulating hormone, and the use of vasopressors, diuretics, and venous thromboembolism prophylactic agents, were optimally performed when warranted. However, we noted suboptimal adherence to certain resource-intensive conditional orders, such as hourly monitoring of urine output (61.4%), hooking to cardiac monitor (53.8%), and performance of 12-lead ECG within 10 minutes (56.8%). Further, only 43.9% of patients were referred to the intensive care unit. Troponin I, calcium, magnesium, and albumin were ordered in excess.

CONCLUSION

Overall adherence rate of physicians to the hospital’s Acute Heart Failure Pathway was satisfactory. Work is needed to improve adherence to hourly urine output monitoring, consistent hooking to cardiac monitor, and timely performance of 12-lead ECG – an effort that begins with expanding in-hospital diagnostic equipment and human resource supply. We recommend continuous pathway implementation with periodic evaluation and stakeholder feedback to further improve quality of care.

Human ; Male ; Female ; Middle Aged: 45-64 Yrs Old ; Adult ; Albumins ; Blood ; Blood Urea Nitrogen ; Calcium ; Cardiology ; Chart ; Charts ; Cohort Studies ; Critical Care ; Critical Pathways ; Diagnostic Equipment ; Disease ; Diuretics ; Echocardiography ; Electrocardiography ; Emergencies ; Emergency Service, Hospital ; Equipment And Supplies ; Evaluation Studies As Topic ; Feedback ; Heart ; Heart Diseases ; Heart Failure ; Hormones ; Hospitals ; Hospitals, General ; Humans ; Hypertension ; Indicators And Reagents ; Infection ; Infections ; Inpatients ; Intensive Care Units ; Internal Medicine ; Lead ; Magnesium ; Male ; Medicine ; Myocardial Ischemia ; Natriuretic Peptide, Brain ; Natriuretic Peptides ; Nitrogen ; Overall ; Oxygen ; Partial Thromboplastin Time ; Patients ; Peptides ; Philippines ; Physicians ; Potassium ; Prothrombin ; Prothrombin Time ; Quality Of Health Care ; Referral And Consultation ; Sodium ; Statistics ; Tertiary Care Centers ; Thorax ; Thromboembolism ; Thromboplastin ; Thyroid Gland ; Time ; Troponin ; Troponin I ; Universities ; Urea ; Urinalysis ; Urine ; Venous Thromboembolism ; Vital Signs ; Work ; Workforce

urine instead of 24-hour (hr) urine collection. Nevertheless, the optimal method for assessing daily sodium intake remains unclear.SUBJECTS/METHODS: Fifteen male (age 32.7 ± 6.5 years) participants were offered 3 meals with a total of 9–10 g salt over 24 hours, and 24-hr urine was collected from the second-void urine of the first day to the first-void urine of the second day. Twenty-four-hr urinary sodium (24UNa) was estimated using Tanaka's equation and the Korean formula, and spot urine Na, potassium (K), chloride (Cl), urea nitrogen (UN), creatinine (Cr), specific gravity (SG) and osmolality (Osm) were measured. The ratios of urinary Na to other parameters were calculated, and correlations with total measured 24UNa were identified.RESULTS: Average 24-hr urine volume was 1,403 ± 475 mL, and measured 24UNa was 143.9 ± 42.1 mEq (range, 87.1–239.4 mEq). Measured 24UNa was significantly correlated with urinary Na/UN (r = 0.560, P < 0.01), urinary Na/Osm (r = 0.510, P < 0.01), urinary Na/Cr (r = 0.392, P < 0.01), urinary Na/K (r = 0.290, P < 0.01), 24UNa estimated using Tanaka's equation (r = 0.452, P < 0.01) and the Korean formula (r = 0.414, P < 0.01), age (r = 0.548, P < 0.01), weight (r = 0.497, P < 0.01), and height (r = 0.393, P < 0.01) in all spot urine samples. Estimated 24UNa based on the second-void spot urine of the first day tended to be more closely correlated with measured 24UNa than were estimates from the other spot urine samples. The significant parameters correlated with the second-void urine of the first day were urinary Na/K (r = 0.647, P < 0.01), urinary Na/Cr (r = 0.558, P < 0.05), and estimated 24UNa using Tanaka's equation (r = 0.616, P < 0.05) and the Korean formula (r = 0.588, P < 0.05).CONCLUSIONS: Second-void urine is more reliable than first-void urine for estimating 24UNa. Urinary Na/K in the second-void urine on the first day is significantly correlated with 24UNa. Further studies are needed to establish the most reliable index and the optimal time of urine sampling for predicting 24UNa.]]>
Creatinine ; Humans ; Male ; Meals ; Methods ; Nitrogen ; Osmolar Concentration ; Potassium ; Sodium ; Sodium, Dietary ; Specific Gravity ; Urea ; Urine Specimen Collection

OBJECTIVETo evaluate the renal protective effect of Tangshenkang Granule () in a rat model of diabetic nephropathy (DN).

METHODSForty male Sprague-Dawley rats were randomly divided into control, DN, Tangshenkang and benazepril groups. DN model was established in the rats of DN, Tangshenkang and benazepril groups. Tangshenkang Granule solution and benazepril hydrochloride solution were intragastrically administered daily to the rats in the Tangshenkang and benazepril groups for 8 weeks, respectively. Urinary albumin and creatinine were detected. The albumin/creatinine (ACR) was calculated in addition to 24 h urinary protein (24-h UPr), serum creatinine (Scr), blood urea nitrogen (BUN), total cholesterol (TC), triglyceride (TG), low-density lipoprotein (LDL), high-density lipoprotein (HDL), and creatinine clearance rate (Ccr). Right kidneys were harvested for pathological observation using periodic acid-silver methenamine-Masson staining. The average glomerular diameter (DG), average glomerular (AG) and mesangial areas (AM) were measured. The thickness of glomerular basement membrane (TGBM) was detected using transmission electron microscope.

RESULTSCompared with rats in the control group, rats in the DN group showed significantly decreased body weight, increased hypertrophy index, 24-h urinary volume, 24-h UPr, ACR, Scr, BUN, Ccr, blood lipids as well as renal pathological indices including DG, AG, AM, AM/AG and TGBM (P <0.05). Compared with the DN group, the weights of rats in the Tangshenkang and benazepril groups were significantly increased, and the renal hypertrophy indices were significantly decreased (P <0.05). The 24-h urinary volumes, ACR, 24-h UPr, Scr, BUN, Ccr, LDL, DG, AG, AM and TGBM were obviously decreased (P <0.05). Compared with the benazepril group, the Tangshenkang group showed significantly decreased levels of ACR, 24-h UPr, AG and AM (P <0.05).

CONCLUSIONSTangshenkang Granule decreased the urinary protein, attenuated the high glomerular filtration rate and improved lipid metabolism in DN rats, and prevented further injury induced by diabetic nephropathy.

Albuminuria ; complications ; Animals ; Basement Membrane ; drug effects ; metabolism ; Blood Urea Nitrogen ; Body Weight ; drug effects ; Creatinine ; blood ; urine ; Diabetic Nephropathies ; blood ; drug therapy ; physiopathology ; urine ; Disease Models, Animal ; Drugs, Chinese Herbal ; pharmacology ; therapeutic use ; Hypertrophy ; Kidney Function Tests ; Kidney Glomerulus ; drug effects ; pathology ; physiopathology ; Lipid Metabolism ; drug effects ; Lipids ; blood ; Male ; Rats, Sprague-Dawley

The aim of the study was to investigate the effects of Siwu decoction on hyperuricemia, kidney inflammation, and dysfunction in hyperuricemic mice. Siwu decoction at 363.8, 727.5, and 1 455 mg·kg(-1) was orally administered to potassium oxonate-induced hyperuricemic mice for 7 days. Serum urate, creatinine, and blood urea nitrogen levels and hepatic xanthine oxidase (XOD) activity were measured. The protein levels of hepatic XOD and renal urate transporter 1 (URAT1), glucose transporter 9 (GLUT9), organic anion transporters 1 (OAT1), ATP-binding cassette subfamily G member 2 (ABCG2), organic cation transporter 1 (OCT1), OCT2, organic cation/carnitine transporter 1 (OCTN1), OCNT2, Nod-like receptor family, pyrin domain containing 3 (NLRP3), apoptosis-associated speck-like protein (ASC), Caspase-1, and interleukin-1β (IL-1β) were determined by Western blotting. Renal histopathology change was obtained following hematoxylin-eosin staining. Our results indicated that Siwu decoction significantly reduced serum urate, creatinine and blood urea nitrogen levels and increased fractional excretion of uric acid in hyperuricemic mice. It effectively reduced hepatic XOD activity and protein levels in this animal model. Furthermore, Siwu decoction down-regulated URAT1 and GLUT9 protein levels, and up-regulated the protein levels of OAT1, ABCG2, OCT1, OCT2, OCTN1, and OCTN2 in the kidney of the hyperuricemic mice. Additionally, Siwu decoction remarkably reduced renal protein levels of NLRP3, ASC, Caspase-1, and IL-1β in the hyperuricemic mice. These results suggested that Siwu decoction exhibited anti-hyperuricemic and anti-inflammatory effects by inhibiting hepatic XOD activity, regulating renal organic ion transporter expression, and suppressing renal NLRP3 inflammasome activation, providing the evidence for its use in the treatment of hyperuricemia and associated kidney inflammation.
Animals ; Blood Urea Nitrogen ; Creatinine ; urine ; Drugs, Chinese Herbal ; administration & dosage ; Humans ; Hyperuricemia ; chemically induced ; drug therapy ; immunology ; urine ; Interleukin-1beta ; genetics ; immunology ; Kidney ; drug effects ; immunology ; Liver ; drug effects ; Male ; Mice ; Organic Anion Transport Protein 1 ; genetics ; immunology ; Sulfuric Acids ; Uric Acid ; urine

In a prospective randomized controlled study, the efficacy and safety of a continuous ambulatory peritoneal dialysis (CAPD) technique has been evaluated using one icodextrin-containing and two glucose-containing dialysates a day. Eighty incident CAPD patients were randomized to two groups; GLU group continuously using four glucose-containing dialysates (n=39) and ICO group using one icodextrin-containing and two glucose-containing dialysates (n=41). Variables related to residual renal function (RRF), metabolic and fluid control, dialysis adequacy, and dialysate effluent cancer antigen 125 (CA125) and interleukin 6 (IL-6) levels were measured. The GLU group showed a significant decrease in mean renal urea and creatinine clearance (-Delta1.2+/-2.9 mL/min/1.73 m2, P=0.027) and urine volume (-Delta363.6+/-543.0 mL/day, P=0.001) during 12 months, but the ICO group did not (-Delta0.5+/-2.7 mL/min/1.73 m2, P=0.266; -Delta108.6+/-543.3 mL/day, P=0.246). Peritoneal glucose absorption and dialysate calorie load were significantly lower in the ICO group than the GLU group. The dialysate CA125 and IL-6 levels were significantly higher in the ICO group than the GLU group. Dialysis adequacy, beta2-microglobulin clearance and blood pressure did not differ between the two groups. The CAPD technique using one icodextrin-containing and two glucose-containing dialysates tends to better preserve RRF and is more biocompatible, with similar dialysis adequacy compared to that using four glucose-containing dialysates in incident CAPD patients. [Clincal Trial Registry, ISRCTN23727549]
Adult ; Aged ; CA-125 Antigen/analysis ; Creatinine/urine ; Dialysis Solutions/*therapeutic use ; Female ; Glomerular Filtration Rate ; Glucans/*therapeutic use ; Glucose/*therapeutic use ; Humans ; Interleukin-6/analysis ; Kidney/physiopathology ; Kidney Failure, Chronic/*therapy ; Male ; Membrane Proteins/analysis ; Middle Aged ; Peritoneal Dialysis ; Peritoneal Dialysis, Continuous Ambulatory ; Urea/urine

In a prospective randomized controlled study, the efficacy and safety of a continuous ambulatory peritoneal dialysis (CAPD) technique has been evaluated using one icodextrin-containing and two glucose-containing dialysates a day. Eighty incident CAPD patients were randomized to two groups; GLU group continuously using four glucose-containing dialysates (n=39) and ICO group using one icodextrin-containing and two glucose-containing dialysates (n=41). Variables related to residual renal function (RRF), metabolic and fluid control, dialysis adequacy, and dialysate effluent cancer antigen 125 (CA125) and interleukin 6 (IL-6) levels were measured. The GLU group showed a significant decrease in mean renal urea and creatinine clearance (-Delta1.2+/-2.9 mL/min/1.73 m2, P=0.027) and urine volume (-Delta363.6+/-543.0 mL/day, P=0.001) during 12 months, but the ICO group did not (-Delta0.5+/-2.7 mL/min/1.73 m2, P=0.266; -Delta108.6+/-543.3 mL/day, P=0.246). Peritoneal glucose absorption and dialysate calorie load were significantly lower in the ICO group than the GLU group. The dialysate CA125 and IL-6 levels were significantly higher in the ICO group than the GLU group. Dialysis adequacy, beta2-microglobulin clearance and blood pressure did not differ between the two groups. The CAPD technique using one icodextrin-containing and two glucose-containing dialysates tends to better preserve RRF and is more biocompatible, with similar dialysis adequacy compared to that using four glucose-containing dialysates in incident CAPD patients. [Clincal Trial Registry, ISRCTN23727549]
Adult ; Aged ; CA-125 Antigen/analysis ; Creatinine/urine ; Dialysis Solutions/*therapeutic use ; Female ; Glomerular Filtration Rate ; Glucans/*therapeutic use ; Glucose/*therapeutic use ; Humans ; Interleukin-6/analysis ; Kidney/physiopathology ; Kidney Failure, Chronic/*therapy ; Male ; Membrane Proteins/analysis ; Middle Aged ; Peritoneal Dialysis ; Peritoneal Dialysis, Continuous Ambulatory ; Urea/urine

The present study investigated the urinary tract toxicity of melamine alone or in combination with cyanuric acid in rats. Male rats were orally administered melamine alone (800 mg/kg) or melamine plus cyanuric acid (50 mg/kg each) for 3 consecutive days. Although melamine treatment did not show any significant difference in body weight, kidney or urinary bladder weight, serum blood urea nitrogen (BUN) or creatinine levels, it caused a decrease in urinary pH and mild histopathological alterations in the kidney and urinary bladder. In contrast, co-administration of melamine and cyanuric acid induced a decrease in body weight, an increase in kidneys and urinary bladder weights, and an elevation in serum BUN and creatinine levels, which were not observed in animals treated with melamine alone. Histopathological examination showed that the incidence and severity of histopathological lesions in the kidney and urinary bladder were much higher than those in the melamine group. Urinalysis revealed an increase in urine occult blood, leukocytes and protein and a decrease in urinary pH. These results indicate that concomitant administration of cyanuric acid synergistically potentiated the urinary tract toxicity induced by melamine in rats. In this study, we first demonstrated the synergistic toxic effects of melamine in combination with cyanuric acid on urinary bladder and urinalysis in rats.
Animals ; Blood Urea Nitrogen ; Body Weight ; Calculi ; Creatinine ; Humans ; Hydrogen-Ion Concentration ; Incidence ; Kidney ; Leukocytes ; Male ; Occult Blood ; Rats* ; Triazines ; Urinalysis ; Urinary Bladder ; Urinary Tract* ; Urine ; Weights and Measures

Drug-induced interstitial nephritis is one cause of acute kidney injury. Although traditional remedies have been widely used in South Korea, Corni fructus-induced interstitial nephritis has not been reported in the general population. A 65-year-old female patient was admitted with sudden onset of gross hematuria after ingesting Corni fructus tea for 2 weeks. Her initial lab findings showed a blood urea nitrogen level of 35.1 mg/dL, creatinine level of 1.7 mg/dL, albumin level of 4.5 g/dL, and hemoglobin level of 10.3 g/dL. Urinalysis revealed SG (1.025), blood (many), protein (+), and WBC (0-3/HPF). Her 24-hour total protein level was 1,120 mg/day. No specific abnormalities were found on serum and urine protein electrophoresis. Kidney biopsy demonstrated severe mononuclear cell infiltration into the renal interstitium with mild tubular atrophy and pericapsular fibrosis. Immediate withdrawal of Corni fructus, appropriate education, and conservative management resulted in gradual restoration of her renal function. This case implies that Corni fructus may be a causative allergen that induces acute interstitial nephritis in some patients.
Acute Kidney Injury ; Aged ; Atrophy ; Biopsy ; Blood ; Blood Urea Nitrogen ; Cornus ; Creatinine ; Education ; Electrophoresis ; Female ; Fibrosis ; Hematuria ; Hemoglobins ; Humans ; Kidney ; Nephritis, Interstitial* ; Pyridines ; Republic of Korea ; Tea ; Thiazoles ; Urinalysis ; Urine

Drug-induced interstitial nephritis is one cause of acute kidney injury. Although traditional remedies have been widely used in South Korea, Corni fructus-induced interstitial nephritis has not been reported in the general population. A 65-year-old female patient was admitted with sudden onset of gross hematuria after ingesting Corni fructus tea for 2 weeks. Her initial lab findings showed a blood urea nitrogen level of 35.1 mg/dL, creatinine level of 1.7 mg/dL, albumin level of 4.5 g/dL, and hemoglobin level of 10.3 g/dL. Urinalysis revealed SG (1.025), blood (many), protein (+), and WBC (0-3/HPF). Her 24-hour total protein level was 1,120 mg/day. No specific abnormalities were found on serum and urine protein electrophoresis. Kidney biopsy demonstrated severe mononuclear cell infiltration into the renal interstitium with mild tubular atrophy and pericapsular fibrosis. Immediate withdrawal of Corni fructus, appropriate education, and conservative management resulted in gradual restoration of her renal function. This case implies that Corni fructus may be a causative allergen that induces acute interstitial nephritis in some patients.
Acute Kidney Injury ; Aged ; Atrophy ; Biopsy ; Blood ; Blood Urea Nitrogen ; Cornus ; Creatinine ; Education ; Electrophoresis ; Female ; Fibrosis ; Hematuria ; Hemoglobins ; Humans ; Kidney ; Nephritis, Interstitial* ; Pyridines ; Republic of Korea ; Tea ; Thiazoles ; Urinalysis ; Urine

PURPOSE: The purpose of this study was to examine the effects of a face-to-face self-management educational program on knowledge, self-care practice and kidney function in patients with chronic kidney disease (CKD) before kidney replacement therapy. METHODS: This study employed a nonequivalent control group, non-synchronized design. Data were collected from 61 patients with CKD visiting an outpatient department of nephrology in a university hospital in Seoul, South Korea. The experimental group (n=31) took the pre-test, then after 3 weeks, face-to-face education and individualized consultation (1st intervention), after a week of self-practice, the 1st post-test, followed by re-enforcement education and consultation (2nd intervention), and 4 weeks later, the 2nd post-test. The control group (n=30) took the pre-test and post-tests at 4 and 8 weeks. RESULTS: Scores for knowledge of CKD and self-care practice over time improved significantly in the experimental group compared to the control group. Kidney function did not improve significantly in the experimental group. CONCLUSION: Health care providers can identify various and individualized needs, and provide effective education and consultation through face to face self-management for patients with chronic irreversible illnesses. Nurses can coordinate for these program by designing and providing systematic and effective education.
Adult ; Aged ; Blood Urea Nitrogen ; Calcium/blood ; Creatinine/blood ; Female ; Glomerular Filtration Rate ; *Health Knowledge, Attitudes, Practice ; Hemoglobins/analysis ; Humans ; Kidney/*metabolism ; Male ; Middle Aged ; *Patient Education as Topic ; Phosphates/blood ; Potassium/urine ; Program Evaluation ; Renal Insufficiency, Chronic/*psychology ; Renal Replacement Therapy ; *Self Care ; Sodium/urine