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Left ventricular enddiastolic volume may be measured using the geometric or count proportional method. The geometric method measures the area of the left ventricle and the length of the major axis in pixels. In the count proportional method, volume is derived from the total counts and the counts in the hottest pixel in the left ventricle. Interpretation the radionuclide bolus appears sequentially in the superior vena cava, right atrium, right ventricle, pulmonary circulation, left side of the heart and aorta. Any changes in this pattern would suggest the presence of a congenital abnormality. Delayed tracer transit on the left side of the heart would suggest mitral or aortic insufficiency. Regional wall motion is analysed by superimposing the end-diastolic outline against the end-systolic image or by viewing the representative cycle in cine-mode. However, it has to be noted that since the study was acquired in only one projection, regional wall motion abnormalities may be difficult to identify in overlapping segments. Ischaemic responses applicable to the diagnosis of coronary artery disease are typically a new onset of a regional wall motion abnormality or a worsening of a previous one, an increase in the endsystolic volume and alterations in diastolic filling parameters. Assessment of right ventricular function, however, may not be as accurate as with the first pass radionuclide angiography method. This imaging modality makes use of an intravenously injected radionuclide that remains in the cardiac chambers in a concentration directly proportional to the blood volume. Data are collected from several hundred cardiac cycles to create an image of the beating heart, presented as a single cardiac cycle. It can be used to assess global and regional wall motion, chamber size and morphology, and ventricular function including ejection fraction. Acquisitions are made at rest or during exercise, or under pharmacological, isometric mechanical, cold-pressor or mental stress. Periodic monitoring of cardiac function helps in the determination of the optimal timing for valvular surgery. Stress testing should be avoided in cases of particular contraindications for exercise, pharmacological procedures or other forms of cardiac challenge. The optimal dose of stannous ions will maximize the amount of technetium bound inside the cell and limit the proportion of circulating free pertechnetate that would be taken up by the thyroid, kidneys and gastric mucosa. For in vivo labelling, the stannous ions, usually provided as a pyrophosphate bone kit, are injected first, followed 20 min later by the 99mTc pertechnetate dose. High resolution collimators improve image quality but require longer imaging times. Procedure (a) Positioning the patient should lie down comfortably to prevent movement during the procedure. Another method is reverse gating, where the last frame ends on the R wave instead of the first frame being assigned to the R wave. Early systolic data are more accurate with forward gating, while end-diastolic data are preserved with reverse gating. A narrow window means more homogeneous beats, making the study more accurate but with a prolonged acquisition time if some arrhythmia is present. Frame mode is the typical acquisition method but list mode is the more memory demanding one. List mode is particularly appropriate for studies of diastolic function and is more flexible in adjusting the beat length window, 184 5. The number of frames depends on the clinical problem, software capabilities and acquisition time available. A higher number of frames improves the temporal resolution, making the image more representative of the variations in chamber volume. Bicycle exercise is preferred and can be performed in both the upright and supine positions: both place similar overall stress on the heart at any given workload. Exercise in the supine position, however, places more strain on the legs and may cause patients, particularly the older or those out of condition, to stop exercising before an adequate cardiovascular stress is reached. Sufficient time should be allowed at each workload for the heart rate to stabilize and for enough image statistics to be acquired for reliable quantification. The period of peak exercise should be of sufficient length for superior image quality. However, prolonging the exercise by reducing the workload may lead to an immediate improvement of the ventricular function and to an underestimation of an eventual ischaemic reponse. An optional post-exercise image may be valuable in predicting functional recovery after revascularization in segments with severe wall motion abnormalities at rest. Alternatives for patients unable to exercise include atrial pacing, cold pressor testing, catecholamine infusion and coronary vasodilators such as dipyridamole or adenosine. It is recommended that the entire cycle be reviewed to obtain optimal information. Fourier transform analysis of the data and the first and third harmonics are used to filter the images and curve, to obtain functional parametric images such as those of phase or amplitude, or fit ventricular volume curves in order to determine systolic and diastolic function. The peak left ventricular filling rate is often a useful parameter to detect early dysfunction. Next, the morphology, orientation and sizes of the cardiac chambers and great vessels are evaluated and reported. Global left ventricular function is assessed qualitatively, followed by a segmental analysis of regional function using a cinematic display. Resting and stress images are displayed side by side to assess changes in chamber size, wall motion and ejection fraction. Quantitative measurements of ventricular systolic and diastolic functions are made. For patients with coronary artery disease, wall motion abnormalities can develop on exercise, with a fall in ejection fraction. Distortion of the left ventricular contour and paradoxical wall motion, usually in the anterior or anteroapical myocardium, are characteristic findings of ventricular aneurysm. Principle Myocardial perfusion scintigraphy uses perfusion radiotracers that are distributed in the myocardium (primarily the left ventricle) in proportion to coronary blood flow. Areas of normal flow exhibit a relatively high level of tracer uptake, while ischaemic regions present a relatively low uptake. Regional coronary blood flow may be compared in conditions of rest, stress or pharmacologically induced vasodilation. In addition to evaluating relative regional blood flow these tracers are, therefore, also markers of myocardial viability. Myocardial perfusion scintigraphy may be performed using either single photon or positron emitting radionuclides. Among the commonly used single photon emitting perfusion tracers are 201Tl and the various 99mTc labelled perfusion tracers (e. While having different physical and pharmacokinetic properties, these tracers have considerably overlapping clinical uses and will therefore be considered in parallel in this section. Clinical indications the clinical indications for myocardial perfusion tomography are summarized in Table 5. The presence of extensive ischaemia or myocardium at risk indicates the need for more invasive work-up, such as coronary angiography. Conversely, the absence of significant ischaemia or myocardium at risk generally rules out the need for intervention. Myocardial perfusion imaging can be performed in various settings: in patients with suspected coronary artery disease, after myocardial infarction or for the assessment of therapy. Myocardial perfusion imaging can also be used to evaluate the pathological significance of coronary lesions already detected by angiography. Angiographic coronary artery disease with a normal stress myocardial perfusion scan has little prognostic significance according to accumulated data. This helps clinicians to determine which patients to manage aggressively with invasive procedures and which ones to manage conservatively.

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Dialysate sodium, serum sodium and mortality in maintenance hemodialysis-Finnian R. Managing comorbidities in oncology: A multisite randomized controlled trial of continuing versus discontinuing statins in the setting of life-limiting illness. Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: a randomized clinical trial. Repeated heating of cooking oils caused thermal oxidation which produces harmful products including free radicals. Hence, repeatedly heated cooking oils may be responsible for an increase in blood pressure or hypertension. The present review compared the effect of few heated vegetable oils on blood pressure and possible mechanisms of the blood pressure raising effect were discussed. Studies have reported that heated oils cause oxidative stress, vascular inflammation leading to endothelial dysfunction. The impaired endothelial function then may interfere with the homeostasis of endothelial derived relaxing and constricting factors. Keywords: Heating, cooking oils, blood pressure, vascular reactivity, inflammation Materials and methods Ovid Medline (published between 1946 and 2015) and Scopus (published between 1946 and 2015) database were used for articles collection. Introduction Hypertension has been associated with cardiovascular morbidity and mortality due to stroke, myocardial infarction and kidney failure [1]. The prevalence of hypertension amongst Malaysian aged more than 30 years old has increased from 32. Various studies in humans and animals have been performed to determine the role of saturated and unsaturated fatty acids in hypertension [4-7]. There is a high tendency for public to reuse the frying oils in cooking to save cost of food preparation [11]. This practice is detrimental to health as repeatedly heated oils undergo a series of chemical reaction known as thermal oxidation. Thermal oxidation products of heated oils include free radicals which are implicated in the pathogenesis of many diseases including hypertension [12]. Oxidative stress and lipid peroxidation have been implicated in the pathogenesis of hypertension and atherosclerosis [13-15]. Oxidative stress-induced endothelial injury impairs endothelial-dependent vasodilation which subsequently increases vascular reactivity and resistance. The study reported that polar compounds which indicate the degradation degree of cooking oil were strongly and positively associated with high blood pressure. On the other hand, the concentration of monounsaturated fatty acids and serum phospholipids were negatively correlated to hypertension. Subsequent studies were undertaken to determine the link between heated oil and blood pressure with emphasis on possible mechanisms of action [24-32]. However, in contrast, heated twice, five times and ten times palm and soy oil increase blood pressure. A recent study has demonstrated linear positive correlation between blood pressure and oxidative stress [18]. On the other hand, there was a negative correlation between blood pressure and antioxidant activities [19]. Previous studies have shown that heated oils cause lipid peroxidation and increase risk of atherosclerosis [20, 21]. This review article compare the effect of heated monosaturated and polyunsaturated cooking oils on blood pressure. The possible mechanism of blood pressure raising effect of heated oil was highlighted. The earlier study that described the detrimental effect of heated vegetable oil on blood pressure was done by Osim et al. The study reported the mean arterial blood pressure of rats following chronic consumption of a diet that contained 15% oxidized palm oil was significantly increased compared to the control and fresh oil group. The detrimental effect of 627 Int J Clin Exp Med 2016;9(2):626-636 Heated cooking oils and blood pressure Table 2. Effect of heated oil on acetylcholine-induced vasodilation and phenylephrine-induced vasoconstriction Acetylcholine- Phenylephrineinduced induced vasoconvasodilation striction Osim et al. The type of animal used in the studies and the duration of the study contributed to the discrepancy in the finding. The duration of study may be attributed to the different finding as the previously mentioned studies [24-31] studied the effect for 24 weeks, whilst Yen et al. The protective effect of antioxidants on heated vegetables oil was also demonstrated by Perez-Hererra et al. This study reported that olive oil polyphenols protected oxidative stress induced by thermal oxidation of oil [34]. This finding again supported the role of stress oxidative and antioxidants in heated oil-induced hypertension. Standard organ bath procedures in determining the vascular reactivity are invasive and practically suitable for animal study only. However these studies investigated in a small-size sample and short-term duration. Thus, it may be responsible once and 10 ten times canola oil induced presfor the blood pressure raising effect of heated ence of nitrotyrosine in the aorta which indicaoil. Postprandial lar altered response except that this study used inflammatory response was increased after noradrenaline as the contracting factor instead ingestion of heated sunflower oil as evidenced of phenylephrine [40]. The effect of heated oil on vascular reactivity were summarized in oil on inflammatory biomarkers was summaTable 2. Effect of heated oil on inflammatory biomarkers Heated oil and inflammatory biomarkers Vascular inflammation, oxidative stress and vascular dysfunction have been reported to play an important role in pathogenesis of cardiovascular disease particularly hypertension and atherosclerosis [41-45]. Altogether, these responses close a vicious, interlinking cycle between inflammation, oxidative stress and endothelial dysfunction leading to the development of hypertension. Vascular dysfunction was also noted with long term feeding with food fried with canola oil [32]. The strong positive correlation between blood pressure and inflammatory biomarkers suggests that vascular inflammation plays important roles in pathogenesis of hypertension with heated oil. These studies, therefore suggest that heated oil induces vascular inflammation which may contribute to vascular dysfunction and hypertension. Oxidative stress At high temperature heated oil undergoes a series of chemical reactions which include oxidation, hydrolysis, polymerization and isomerization. The reactions are deleterious to the stability of fatty acids and other biochemical parameters of the oil [47, 48]. Thermally heated cooking oil has been shown to cause 15-fold, 8-fold, 39-fold, 19-fold, 8. The primary lipid oxidation products such as peroxides and hydro peroxides are unstable; they react rapidly with each other to form secondary lipid oxidation products. Whilst the nonvolatile compounds which includes carbonyls, polymeric and cyclic fatty acids. Several studies have examined the effect of heated vegetable oils on oxidative stress biomarkers in animal fed heated oil. Total phenolics deteriorated with successive frying of virgin olive oil with only 20-30% of total phenolics left in the oil after eighth frying [51]. After five times heating, more than 95% of -tocopherol and -tocotrienol in the palm oil were destroyed. Ingestion of thermally oxidized sunflower oil increased postprandial plasma peroxides (5-11%) significantly in a trial for both men with stable coronary artery disease and healthy men [53]. These findings therefore suggested that heating cause oxidative stress which may contribute to vascular dysfunction and hypertension. Nitric oxide and blood pressure regulating enzymes Vascular endothelium produces a vast range of chemical mediators to regulate cellular adhesion, smooth muscle cell proliferation and vascular wall inflammation. Therefore, it is suggested that excessive oxidation compounds from lipid oxidation may induce oxidative stress and impairs endothelial function which regulates blood pressure [59-61]. It was shown that at the smallest and highest heating frequency, the percentage increase was highest for heated soy compared to heated corn and palm oil. Int J Clin Exp Med 2016;9(2):626-636 Heated cooking oils and blood pressure Address correspondence to: Dr.


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For consistency in both descriptive statistics and analysis, we regard a move to be a "true" move only if it was out of the neighborhood in which the woman was residing. Although about 55% of women moved from Greater Accra (which includes the urban center of Accra), residential moves were observed from all regions of Ghana. However, in many cases, women reported moving to unknown neighborhoods, with almost 30% of women reporting not knowing anyone in the location to which they moved. Region moved from Foreign countr y Upper East Upper West Northern Brong Ahafo Ashanti Eastern Volta Greater Accra Central Western Reason given for past move Other Study Forced to leave old place Found better place Work Marriage 0. In the first part, we investigate the effect of migration on the total number of children ever born. We use a Poisson model to compare the total fertility of those who had never moved with those who had moved within the area of Greater Accra and with 43 those who had moved from another region. We conduct Poisson regressions with a log link to investigate whether having moved has an effect on total fertility: ~ ( ) Here, Yi is one of three outcomes: the total number of children ever born, children ever born and still alive, or children born since 2005 and still alive. The incidence rate of birth, explanatory variables of interest and individual covariates Xi: = exp( + + + ), is modeled by our where MovedWithinAccrai is an indicator for whether the individual had moved but only within Accra, and In-migratedFromOutsideAccrai is an indicator for whether the individual moved from outside the Greater Accra region to inside the Greater Accra region. The parameters and are the parameters of interest-the effect of moving on completed fertility compared with those who had never moved. We also interact age group with education because the effect of age on fertility may differ across education groups. Move status was determined by whether an individual woman claimed to have ever moved outside the neighborhood that she was living in. Moves within the same neighborhood were not determined to be substantial enough to constitute a "true" move and thus were not counted as having moved. Event-History Analysis for Pregnancy Outcomes In the second part of the analysis, we conduct an event-history analysis using a person-year data structure. Each person-year between the ages of 15 and 47 and between the years of 1980 and 2009 constitutes an 44 observation in the analysis. We chose these ages and years so that each pregnancy outcome would yield positive probabilities of occurring in our data [12]. Because we are interested in the effect of residential duration on reproductive health outcomes in a given year, we eliminate multiple pregnancy observations that were claimed to have happened in the same year. These covariates were chosen based on the theoretical model and previous literature [12,17]. Zi is a this could be possible if a woman has multiple stillbirths in the same year, for example. Again, we interact age group with education because the effect of age on a pregnancy outcome may differ across education groups. Pregnancy and reproductive health indicators were obtained from detailed pregnancy histories of all women who had given birth. The year of the pregnancy was recorded for all pregnancies on the roster, as well as the outcome of the pregnancy. Induced abortion was differentiated from spontaneous abortion (lost birth or miscarriage) by a positive response to the question, "Did you or someone else put a hand to this pregnancy? However, stigma of abortion is quite high in Ghana, resulting in potentially large measurement error owing to reporting bias. We thus also combine miscarriage and abortion for one estimate of lost birth from either cause. Accounting for Selection Bias Finally, in the third part of the analysis, we use individual fixed effects to account for the systematic differences between those who choose to move and those who do not. Using fixed effects accounts for all characteristics that are unique to that individual and constant over time, including unobserved characteristics such as fertility preferences, risk aversion, and general attitudes. Because we wish to analyze differences observed within each woman over time, our analysis is restricted to women who moved at least once. The regression below describes our linear probability fixed-effects model: = + (0 - 24. Those who never moved were younger, were less likely to be married, and had fewer total children than those who had moved. From age 15 to about 35, the observed profiles are directly atop of each other, but those of other regions are dramatically elevated, showing the contrast between rural and urban fertility patterns. Goodness-of-fit chi-squared tests for all models were statistically insignificant, indicating that the Poisson model is appropriate and fits the data. For example, an Akan woman over age 40 who has been married and did not finish primary school had predicted numbers of children of 5. We construct a panel data set, where one observation is a person-year between the ages of 15 to 47 and between the years 1980 and 2009. The final sample size for our data is 31,936 person-years, composed of 2,022 women. Of these, 3,364 were live births, 520 were lost births (either miscarriage or induced abortions), and 105 were stillbirths. Of the 520 lost births, 206 were identified as induced abortions, and 314 were reported as miscarriages. A study of a hospital in Accra found that 37% of the women in the sample who presented with complications from induced abortions had obtained a previous induced abortion [30]. The measure of abortions per 100 pregnancies is low in our sample compared with other measures from recent urban surveys in Accra: 7 the process for how we obtained the sample size is described in Appendix Figure B. For person-years with a shorter residential duration, women were younger, less likely to be married, and less likely to already have a child than those who had lived in the area longer. However, they were most likely to have married in the past year compared with any other duration and compared with those who had never moved. Because we create the person-year data set, we inevitably have pregnancy years occurring in the same year as moves. For person-years in which a pregnancy occurs, we can distinguish whether the pregnancy or the move came first in the year if both birth month and month of move are not missing. Thus, we do not want to induce bias by categorizing our explanatory variable by our outcome variable. Therefore, the coefficient on 1 should be interpreted as an association between a migration and pregnancy outcome that occurred in the same year, not a causal effect of moving on pregnancy. Logistic models were substantively similar to linear probability models, and results are shown in Appendix Table B. There was no significant effect of any residential duration on stillbirth compared with never-movers. When all covariates were at their means, the change in risk of pregnancy represented an increase from 11. The increase in risk of lost birth was more than proportional to the increase in risk of pregnancy. Having completed at least middle school was negatively associated with pregnancy and lost birth in the lowest age group. Being married was positively associated with pregnancy and live birth, but not with lost birth or miscarriage. Having been married within the past year was also positively and strongly significantly associated with pregnancy and live birth. As residential duration increased, risk of pregnancy, live birth, and lost birth decreased.

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She is the principal investigator on a number of multicenter Canadian studies and has developed a group of investigators known as the Canadian Renal Disease Alliance Group. She is active in the following organizations: the American Society of Nephrology, the International Society of Nephrology, and the Kidney Foundation of Canada, as well as locally in the University of British Columbia, Research Advisory Committee at St. She is currently on the editorial board of Nephrology Dialysis Transplantation and for the American Journal of Kidney Disease (2001) and reviews articles for Peritoneal Dialysis International, Kidney International, Journal of American Society of Nephrology, and Canadian Family Practice. He has served as Board Member of the American Geriatric Society, as Editor 290 Part 11. His research interests are in the area of physiology of aging, glucose/ insulin physiology, and sarcopenia. He is Principal Investigator of a Program Project on the biomedical aspects of aging. He has served as Scientific Reviewer of several nephrology journals and has over 90 publications. He is a member of the American Society of Nephrology and the American Diabetes Association. His research areas currently focus on areas of renal pathology, including key clinical and morphologic aspects of fibrillary glomerulopathy and collapsing glomerulopathy. He is a noted regional, national, and international lecturer on renal research and renal pathology, and he is a recipient of the Annual Irving M. He is widely published in journals including the Journal of Cell Biology as well as the American Journal of Physiology, Journal of the American Society of Nephrology, Journal of Clinical Investigation, Endocrinology, and Kidney International. His research areas include diabetes mellitus, diabetic nephropathy, and cardiovascular disease. He participates from the base of the central laboratory for several clinical trials and studies. He has reported receiving several grants to conduct research on diabetes, its complications, and macrovascular disease. She serves as patient education coordinator for the Missouri Kidney Program Center for Renal Education and staffs the Life Options Rehabilitation Resource Center. Ms Witten has published over 20 papers, co-authored a chapter on kidney disease in the Encyclopedia of Disability and Rehabilitation, and made numerous presentations on rehabilitation topics. She has consulted on projects for the Health Care Financing Administration, the Rehabilitation Services Administration, and the Social Security Administration. She completed her PhD in Clinical Investigation from Johns Hopkins University School of Hygiene and Public Health. Dr Furth has served as a reviewer for several journals and published over 25 peer-review manuscripts and invited reviews, numerous abstracts, and book chapters. She has received extensive research support from several organizations for her investigations in pediatric nephrology. She is a member of the Clinical Affairs Committee of the American Society of Pediatric Nephrology Clinical Science Committee and a symposium speaker at the Congress of the International Society for Pediatric Nephrology Association. She has conducted seminars and lectures, and been interviewed for Reuters Health News On-Line. Dr Furth is the recipient of the Young Investigator Award and the Johns Hopkins Comprehensive Transplant Center Clinical Research Award. Dr Hogg has published over 94 original papers, book chapters, and invited reviews on children with chronic kidney failure. He is a member of the Nephrology Section of the American Academy of Pediatrics, the International Society of Nephrology, and the American Society of Nephrology. He is past Chief of the Department of Pediatrics at Baylor University Medical Center, past Director of Renal Micropuncture Laboratory at the University of Texas Health Center at Dallas, and past Clinical Associate Professor of Pediatrics at the University of Texas Southwestern Medical School. Dr Hogg has reported receiving research grants from Astra Zeneca, Merck, Novartis, Parke-Davis, and Pfizer. He completed his Research Fellowship at the University of Heidelberg, Germany, and his Clinical Fellowship at Stanford University. His research interests are in the area of the progression of glomerular disease, glomerular pathology, and mechanisms of proteinuria. He has been an active reviewer for several journals and has published over 30 peer-reviewed articles. He has been a Fellow of the Alexander von Humboldt Foundation and is a member of the International Society of Nephrology, the American Society of Nephrology, the American Society of Pediatric Nephrology, the International Pediatric Nephology Association, and the Society for Pediatric Research. He completed his Fellowship in Pediatric Nephrology at Washington University School of Medicine and St. He is founding member and officer of the American Association of Medical Chronobiology and Chronotherapeutics. He is a member of the American Society of Nephrology, the Southwest Pediatric Nephrology Study Group, the American Society of Pediatric Nephrology, and the International Pediatric Nephrology Association. He has reviewed dozens of abstracts and manuscripts for many nephrology and physiology journals and is on the editorial boards of Seminars in Nephrology and the American Journal of Physiology and Renal Physiology. Dr Schwartz has published over 170 papers, including articles, books, abstracts, and letters in nephrology. He is a member of the American Society for Clinical Investigation, American Society of Pediatric Nephrology, the International Pediatric Nephrology Association, the Society for Pediatric Research, and the American Society of Nephrology. James Smith, Nadine Ferguson, Donna Fingerhut, and Kerry Willis, PhD, were instrumental in coordinating the project. Stefan Armstrong, consultant editor, provided invaluable assistance in preparing the report. The Work Group is indebted to the Evidence Review Team, who worked tirelessly to assemble the evidence and creatively to synthesize the information. The Work Group appreciates the careful review of the draft guidelines and suggestions for improvement by external reviewers. Each comment was carefully considered and, whenever possible, suggestions for change were incorporated into the final report. Participation in the review does not necessarily constitute endorsement of the content of the report by the individuals or the organization or institution they represent. The National Kidney Foundation, as well as the Work Group, recognize the support of Amgen. The National Kidney Foundation is proud to partner with Amgen on this important initiative. As Chair of the Work Group, I personally wish to thank the other members of the Work Group who volunteered their time, effort, wisdom, and humor to this project. Their willingness to think about the ``big picture' while steadfastly adhering to accuracy about ``small details' is responsible for the breadth and depth of these guidelines. Iseki K, Iseki C, Ikemiya Y, Fukiyama K: Risk of developing end-stage renal disease in a cohort of mass screening. Dahlquist G, Rudberg S: the prevalence of microalbuminuria in diabetic children and adolescents and its relation to puberty. Chiumello G, Bognetti E, Meschi F, Carra M, Balzano E: Early diagnosis of subclinical complications in insulin dependent diabetic children and adolescents. Laborde K, Levy-Marchal C, Kindermans C, Dechaux M, Czernichow P, Sachs C: Glomerular function and microalbuminuria in children with insulin-dependent diabetes. Murakami M, Yamamoto H, Ueda Y, Murakami K, Yamauchi K: Urinary screening of elementary and junior high-school children over a 13-year period in Tokyo. A six-year study of normal infants, preschool, and schoolage populations previously screened for urinary tract disease. Guidance for Industry Pharmacokinetics in Patients with Impaired Renal Function: Study Design, Data Analysis and Impact on Dosing and Labeling. Dusing R, Weisser B, Mengden T, Vetter H: Changes in antihypertensive therapy: the role of adverse effects and compliance. Matching the Intensity of Risk Factor Management with the Hazard for Coronary Disease Events. Profiles of General Demographic Characteristics: 2000 Census of Population and Housing, United States. Agarwal R, Nicar M: A comparative analysis of formulas used to predict creatinine clearance.

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Following intravenous administration, plasma clearance of valsartan is about 2 L/h and its renal clearance is 0. The apparent clearance of valsartan following oral administration is approximately 4. Pediatric: In a study of pediatric hypertensive patients (n=26, 1 to 16 years of age) given single doses of a suspension of Diovan (mean: 0. Gender: Pharmacokinetics of valsartan does not differ significantly between males and females. Valsartan is not removed from the plasma by hemodialysis [see Use in Specific Populations (8. Drug Interaction Studies No clinically significant pharmacokinetic interactions were observed when Diovan (valsartan) was coadministered with amlodipine, atenolol, cimetidine, digoxin, furosemide, glyburide, hydrochlorothiazide, or indomethacin. The valsartanatenolol combination was more antihypertensive than either component, but it did not lower the heart rate more than atenolol alone. Coadministration of valsartan and warfarin did not change the pharmacokinetics of valsartan or the time-course of the anticoagulant properties of warfarin. Coadministration of inhibitors of the uptake transporter (rifampin, cyclosporine) or efflux transporter (ritonavir) may increase the systemic exposure to valsartan. Mutagenicity assays did not reveal any valsartan-related effects at either the gene or chromosome level. These assays included bacterial mutagenicity tests with Salmonella (Ames) and E coli; a gene mutation test with Chinese hamster V79 cells; a cytogenetic test with Chinese hamster ovary cells; and a rat micronucleus test. Valsartan had no adverse effects on the reproductive performance of male or female rats at oral doses up to 200 mg/kg/day. These kidney effects in neonatal rats represent expected exaggerated pharmacological effects that are observed if rats are treated during the first 13 days of life. The studies allowed comparison of once-daily and twice-daily regimens of 160 mg/day; comparison of peak and trough effects; comparison (in pooled data) of response by gender, age, and race; and evaluation of incremental effects of hydrochlorothiazide. Administration of valsartan to patients with essential hypertension results in a significant reduction of sitting, supine, and standing systolic and diastolic blood pressure, usually with little or no orthostatic change. In most patients, after administration of a single oral dose, onset of antihypertensive activity occurs at approximately 2 hours, and maximum reduction of blood pressure is achieved within 6 hours. At higher doses, however (160 mg), there is little difference in peak and trough effect. During repeated dosing, the reduction in blood pressure with any dose is substantially present within 2 weeks, and maximal reduction is generally attained after 4 weeks. In long-term follow-up studies (without placebo control), the effect of valsartan appeared to be maintained for up to 2 years. Abrupt withdrawal of valsartan has not been associated with a rapid increase in blood pressure. The blood pressure-lowering effect of valsartan and thiazide-type diuretics are approximately additive. The 7 studies of valsartan monotherapy included over 2,000 patients randomized to various doses of valsartan and about 800 patients randomized to placebo. Doses below 80 mg were not consistently distinguished from those of placebo at trough, but doses of 80, 160 and 320 mg produced dose-related decreases in systolic and diastolic blood pressure, with the difference from placebo of approximately 6-9/3-5 mmHg at 80 to 160 mg and 9/6 mmHg at 320 mg. Patients with an inadequate response to 80 mg once daily were titrated to either 160 mg once daily or 80 mg twice daily, which resulted in a similar response in both groups. In controlled trials, the antihypertensive effect of once-daily valsartan 80 mg was similar to that of once-daily enalapril 20 mg or once-daily lisinopril 10 mg. There are no trials of Diovan demonstrating reductions in cardiovascular risk in patients with hypertension, but at least one pharmacologically similar drug has demonstrated such benefits. There was essentially no change in heart rate in valsartan-treated patients in controlled trials. Pediatric Hypertension the antihypertensive effects of Diovan were evaluated in two randomized, double-blind clinical studies. In a clinical study involving 261 hypertensive pediatric patients 6 to 16 years of age, patients who weighed < 35 kg received 10, 40 or 80 mg of valsartan daily (low, medium and high doses), and patients who weighed 35 kg received 20, 80, and 160 mg of valsartan daily (low, medium and high doses). Renal and urinary disorders, and essential hypertension with or without obesity were the most common underlying causes of hypertension in children enrolled in this study. At the end of 2 weeks, valsartan reduced both systolic and diastolic blood pressure in a dose-dependent manner. Overall, the three dose levels of valsartan (low, medium and high) significantly reduced systolic blood pressure by -8, -10, -12 mm Hg from the baseline, respectively. Patients were re-randomized to either continue receiving the same dose of valsartan or were switched to placebo. In patients who continued to receive the medium and high doses of valsartan, systolic blood pressure at trough was -4 and -7 mm Hg lower than patients who received the placebo treatment. In patients receiving the low dose of valsartan, systolic blood pressure at trough was similar to that of patients who received the placebo treatment. Overall, the dose-dependent antihypertensive effect of valsartan was consistent across all the demographic subgroups. In a clinical study involving 90 hypertensive pediatric patients 1 to 5 years of age with a similar study design, there was some evidence of effectiveness, but safety findings for which a relationship to treatment could not be excluded mitigate against recommending use in this age group [see Adverse Reactions (6. Other background therapy included diuretics (86%), digoxin (67%), and beta-blockers (36%). At the end of the trial, patients in the valsartan group had a blood pressure that was 4 mmHg systolic and 2 mmHg diastolic lower than the placebo group. There were two primary end points, both assessed as time to first event: all-cause mortality and heart failure morbidity, the latter defined as all-cause mortality, sudden death with resuscitation, hospitalization for heart failure, and the need for intravenous inotropic or vasodilatory drugs for at least 4 hours. The number of black patients was small and does not permit a meaningful assessment in this subset of patients. In the combination group, the dose of valsartan was titrated from 20 mg twice daily to the highest tolerated dose up to a maximum of 80 mg twice daily; the dose of captopril was the same as for monotherapy. The population studied was 69% male, 94% Caucasian, and 53% were 65 years of age or older. The data were assessed to see whether the effectiveness of valsartan could be demonstrated by showing in a noninferiority analysis that it preserved a fraction of the effect of captopril, a drug with a demonstrated survival effect in this setting. Valsartan would be considered effective if it preserved a meaningful fraction of that effect and unequivocally preserved some of that effect. Pregnancy: Advise female patients of childbearing age about the consequences of exposure to Diovan during pregnancy. Ask patients to report pregnancies to their healthcare provider as soon as possible [see Warnings and Precautions (5. Lactation: Advise women not to breastfeed during treatment with Diovan [see Use in Specific Populations (8. Symptomatic Hypotension: Advise patients that lightheadedness can occur, especially during the first days of therapy, and that it should be reported to their healthcare provider. Tell patients that if syncope occurs to discontinue Diovan until the physician has been consulted. Caution all patients that inadequate fluid intake, excessive perspiration, diarrhea, or vomiting can lead to an excessive fall in blood pressure, with the same consequences of lightheadedness and possible syncope [see Warnings and Precautions (5. Hyperkalemia: Advise patients not to use salt substitutes without consulting their healthcare provider [see Drug Interactions (7. This leaflet does not take the place of talking with your doctor about your medical condition or treatment. Talk to your doctor about other ways to lower your blood pressure if you plan to become pregnant. It is used in adults to: lower high blood pressure (hypertension) in adults and children, 6 to 16 years of age. Blood pressure is the force in your blood vessels when your heart beats and when your heart rests. Medicines that lower your blood pressure lower your chance of having a stroke or heart attack. High blood pressure makes the heart work harder to pump blood throughout the body and causes damage to the blood vessels. If high blood pressure is not treated, it can lead to stroke, heart attack, heart failure, kidney failure and vision problems.

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Evaluation of a point-of-care assay for cardiac markers for patients suspected of acute myocardial infarction. Cardiac markers and their point-of-care testing for diagnosis of acute myocardial infarction. Emergency department multimarker pointof-care testing reduces time to cardiac marker results without loss of diagnostic accuracy. Evaluation of a bedside whole-blood rapid troponin T assay in the emergency department. Altinier S, Zaninotto M, Mion M, Carraro P, Rocco S, Tosato F, Point-of-care testing of cardiac markers: results from an experience in an emergency department. Cardiac markers of acute coronary syndromes: is there a case for point-of-care testing? Evaluation of quantitative cardiac biomarker point-of-care testing in the emergency department. Ninety-minute exclusion of acute myocardial infarction by use of quantitative point-of-care testing of myoglobin and troponin I. The evolution of a new standard of hospital care: paradigm shift to the emergency department and the role of pointof-care testing. Decreased patient charges following implementation of pointof-care cardiac troponin monitoring in acute coronary syndrome patients in a community hospital cardiology unit. Point-of-care testing reduces length of stay in emergency department chest pain patients. Integration between the tele-cardiology unit and the central laboratory: methodological and clinical evaluation of point-ofcare testing cardiac marker in the ambulance. Prehospital testing for troponin T in patients with suspected acute myocardial infarction. Emergency medicine career paths less traveled: cruise ship medicine, Indian health, and critical care medicine. Katrina, the tsunami, and point-of-care testing: optimizing rapid response diagnosis in disasters. Use of B-type natriuretic peptide in the evaluation and management of acute dyspnea. Importance of time to reperfusion for 30-day and late survival and recovery of left ventricular function after primary angioplasty for acute myocardial infarction. Relationship of symptom-onset-to-balloon time and door-to-balloon time with mortality in patients undergoing angioplasty for acute myocardial infarction. Quantitative analysis of the admission electrocardiogram identifies patients with unstable coronary artery disease who benefit the most from early invasive treatment. The use of performance improvement methods to enhance emergency department patient satisfaction in the United States: a critical review of the literature and suggestions for future research. Predictors of emergency department patient satisfaction: stability over 17 months. Evaluating instruments for quality: testing convergent validity of the consumer emergency care satisfaction scale. Patient and primary care physician satisfaction with chest pain unit and routine care. Determining factors of patient satisfaction for frequent users of emergency services in a medical center. Evaluation of a fast track unit: alignment of resources and demand results in improved satisfaction and decreased length of stay for emergency department patients. A multifaceted intervention improves patient satisfaction and perceptions of emergency department care. Point-of-care immunotesting: approaching the analytical performance of central laboratory methods. Evidence-based decision limits for cardiac troponin: low-level elevation and prognosis. Prognostic value of low-level cardiac troponin-I elevations in patients without definite acute coronary syndromes. Feedback was captured by audiotape, and issues were discussed in detail by conference call. This rapid growth implies a widespread acceptance of the use of point-of-care coagulation assays, yet it is unclear whether documentation exists showing a clinical advantage to these methodologies. The purpose of this guideline is to evaluate the available literature and identify those studies, if any, that objectively demonstrate the utility of point-of-care coagulation testing compared with more traditional laboratory analyses. The term "coagulation testing" is used to describe an evergrowing selection of diagnostic tests. Is there evidence of improved clinical outcome from the use of point-of-care coagulation testing? What is the evidence that the current "standards of care" in point-of-care coagulation are appropriate? Also left to later updates are the clinical utility of these assays for monitoring novel anticoagulants such as direct thrombin inhibitors and direct factor Xa inhibitors, as well as the use of available electronic tools for management of anticoagulation therapy. There are insufficient data to allow recommendations based on specific instrumentation for these tests, and it must be the responsibility of the individual facility to evaluate available systems before implementation in a clinical setting. Although many of the studies described in this document were performed using point-of-care instruments that are no longer available in the marketplace, the value of the studies remains and should not be discounted. Articles identified from author collections were only included if they are indexed on one of the 3 public search engines. These searches were defined by the test name and any of the terms "bedside," "point of care," "near patient," or "whole blood. Such studies were excluded from further consideration because they do not directly address the clinical utility of these systems. An overview of publications dealing with correlation analyses can be found in Zimmerman (2). All 3 studies identified a subpopulation of patients determined to have bleeding complications after heparin reversal with protamine. Both groups found significant reductions in postoperative bleeding and blood product usage in the algorithm group compared with that of patients transfused by routine procedures (central laboratory test results (12) or clinician discretion (13)). The third trial, conducted by Capraro and colleagues (14), did not introduce point-of-care testing for transfusion until after the patients left the operating suite. In contrast to the other studies, these investigators found no difference in bleeding or blood-product usage between the 2 groups across the hospital stay. In fact, the algorithmcontrolled group received more platelets during the first hour than the control group. The authors suggest that this difference may be due to the use of the bleeding time to define the need for platelet transfusion. One explanation could be that the earlier directed transfusion therapy may have more efficiently corrected the hemostatic problems. The point-of-care group had a higher percentage of patients in therapeutic range at 12 and 24 h, less severe or moderate bleeding, and fewer transfusions that the laboratory group (P 0. Three trials were identified evaluating the use of point-ofcare coagulation assays to guide transfusions after cardiac surgery Ar ch iv ed Coagulation quickly. Although the time between sample draw and dose adjustment was significantly shorter for the point-of-care group (P 0. The need to change procedures to optimize the advantages of point-of-care testing was directly demonstrated by Nichols and coworkers (17) in their prospective, nonrandomized analysis of the effect of point-of-care testing on patient wait times before and after elective invasive cardiology and radiology procedures. The authors conclude that point-of-care testing must be integrated into clinical-management pathways if the benefits of the reduced turnaround times are to have positive clinical impact. These trials showed improved patient outcomes (12, 13) or no effect on outcome (14) after cardiac surgery and reduced wait times surrounding interventional cardiology and radiology procedures (17). In addition to evaluating the correlation of the point-of-care system (CoaguChek (22, 24), ProTime (23)), patient and clinician satisfaction was assessed by questionnaire. Satisfaction was the only endpoint evaluated in the study by Choudry and colleagues (26). In these studies, both the patients and the clinicians preferred using fingerstick samples on the point-of-care system to venous sampling for laboratory testing. This is a rapidly growing management strategy for patients receiving long-term vitamin K antagonist anticoagulation in which a highly experienced, dedicated staff can help to provide optimal management to this patient population (25).

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Monitoring dietary protein intake by 24-h urine collection for urea excretion is recommended [6]. Salt intake can be monitored by measuring sodium in 24-h urine collection or chloride if a patient is receiving sodium bicarbonate therapy. The higher urine volumes were associated with higher blood pressure and lower serum sodium concentration. In animal models, hyperlipidemia was shown to cause formation of glomerular foam cells and glomerulosclerosis, which was ameliorated by statin therapy [91]. A recent meta-ana lysis found a modest effect of statins on reduction of kidney disease progression of 1. In nephrotic syndrome, hyperlipidemia can promote nephrosclerosis and sustained hyperlipidemia will accelerate atherosclerosis. Statins have pleotrophic effects that inhibit macrophage/monocyte infiltration into the glomerulus and thus prevent mesangial proliferation, decrease inf lammation and oxidative stress, and reduce podocyte damage [91]. Recommendations In summary, hyperlipidemia may promote kidney disease progression and treatment with statins may ameliorate this process. In animal models there is accumulation of ammonia in the nephron, which can directly activate the alternative complement pathway, leading to tubulointerstitial damage [100]. In addition, chronic uremic acidosis promotes increased protein metabolism as well as bone loss, which occurs due to increased osteoclastic activity to enhance carbonate resorption from bone. It reduces protein catabolism, which may be beneficial in proteinuric kidney disease and slows bone resorption, limiting bone loss. Excess phosphate promotes bone disease and is known to be an independent risk factor for all-cause and cardiovascular mortality [102]. Hyperphosphatemia and elevated calcium/ phosphorous product were shown to cause more rapid progression of kidney disease in an observational study of 985 patients with a median follow-up of 2 years [104]. The endocrine effects of vitamin D are widely recognized, however, the paracrine effects mediated through local 1-a hydroxylase are less appreciated. It has been postulated that in the kidney vitamin D may be important for maintaining podocyte health, suppressing renin gene expression, and preventing inflammation and fibrosis [105]. These data suggest that reduced 25-hydroxy vitamin D is associated with factors that are known to facilitate progression of kidney disease. Bicarbonate therapy slows chronic kidney disease progression and development of end-stage renal disease. We recommend treatment to reach a goal 25-hydroxy vitamin D level of greater than 30 ng/ml. Experimental data suggest that uric acid stimulates afferent arteriolar vascular smooth muscle proliferation and intraglomerular hypertension, which leads to glomerulosclerosis and interstitial fibrosis [112]. Epidemiologic studies found serum uric acid levels to be an independent risk factor for the development and progression of kidney disease [113]. Level of evidence High High High High High Goals/comments Goal systolic blood pressure in the 120s if tolerated. May be antiproteinuric and prevent kidney disease progression Growing evidence of antiproteinuric effect at low doses. The mechanism of the allopurinol effect is not clear, but may be related to inhibition of xanthine oxidase rather than lowering uric acid. Monitor proteinuria in lupus nephritis patients using a urine protein-to-creatinine ratio based on 24-h urine collection because spot protein-to-creatinine ratios are inaccurate. The goal for proteinuria management is to achieve a level of less than 500 mg/day. Blood pressure control Hypertension is a major and modifiable risk factor for progression of kidney disease, and cardiovascular morbidity and mortality. This combination may be more harmful than beneficial at lower levels of proteinuria. Salt intake should be monitored with 24-h urine collections for sodium with a goal of less than 100 mmol/24 h. Statin therapy has been shown to mitigate renal injury in those with hyperlipidemia. Uremic acidosis Acidosis activates the alternative complement pathway and may cause tubulointerstital damage. The goal for acidosis management is to achieve a serum bicarbonate level of >20 mg/dl. Vitamin D deficiency Vitamin D deficiency is common in systemic lupus erythematosus and is associated with cardiovascular risk. Furthermore, the combination of allopurinol and azathioprine should be used with caution due to the increased risk for myelosuppression when used in combination. Patients in the diet group had a significant weight loss while the usual diet group had significant weight gain. Proteinuria decreased by 31% in the diet group and increased in the control group. Renal function was stable in the protein reduction group but worsened in the usual diet group [116]. Based on ambulatory blood pressure monitoring, smokers have higher blood pressures than nonsmokers. A recent observational trial evaluated 40,619 patients and found that even in nondiabetic and nonhypertensive patients, smoking was an independent risk factor for microalbuminuria [117]. Several retrospective studies have demonstrated an association between cigarette smoking and kidney disease progression in patients with glomerulonephritis [118,119]. Financial & competing interests disclosure the authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. Premature morbidity from cardiovascular and cerebrovascular diseases in women with systemic lupus erythematosus. Age-specific incidence rates of myocardial infarction and angina in women with systemic lupus erythematosus: comparison with the Framingham Study. Grading evidence and recommendations for clinical practice guidelines in nephrology. Predictors of the progression of renal disease in the Modification of Diet in Renal Disease Study. Association of single measurements of dipstick proteinuria, estimated glomerular filtration rate, and hematocrit with 25-year incidence of end-stage renal disease in the multiple risk factor intervention trial. Evaluation of the Chronic Kidney Disease Epidemiology Collaboration equation for estimating the glomerular filtration rate in multiple ethnicities. Urinary albumin excretion predicts cardiovascular and noncardiovascular mortality in general population. Albuminuria and risk of cardiovascular events, death, and heart failure in diabetic and nondiabetic individuals. Progression of chronic kidney disease: the role of blood pressure control, proteinuria, and angiotensin-converting enzyme inhibition: a patient-level meta-ana lysis. Proximal tubular epithelial hyperplasia in patients with chronic glomerular proteinuria. This study finds random spot protein-tocreatinine ratios to be unreliable estimates of proteinuria in patients with lupus nephritis. Spot urine protein/creatinine ratios are unreliable estimates of 24 h proteinuria in most systemic lupus erythematosus nephritis flares. Random spot urine protein/creatinine ratio is unreliable for estimating 24-hour proteinuria in individual systemic lupus erythematosus nephritis patients.

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Negative impact on patients; or No relative impact on either a frequent condition with a substantial burden of suffering; or An infrequent condition with a significant impact on the individual patient level. For each stratum, the Task Force uses explicit criteria as general guidelines to assign one of three grades of evidence: good, fair, or poor. Good or fair quality evidence for the entire preventive service must include studies of sufficient design and quality to provide an unbroken chain of evidence-supported linkages that generalize to the general primary care population and connect the preventive service with health outcomes. Poor evidence contains a formidable break in the evidence chain, such that the connection between the preventive service and health outcomes is uncertain. For services supported by overall good or fair evidence, the Task Force uses outcomes tables to help categorize the magnitude of benefits, harms, and net benefit from implementation of the preventive service into one of four categories: substantial, moderate, small, or zero/negative. It gives an "I" recommendation in situations in which the evidence is insufficient to determine net benefit (Harris et al. Following the independent review of the evidence, a consensus meeting was held to discuss discrepancies in ratings and formulate recommendations. Where existing literature was ambiguous or conflicting, or where scientific data was lacking on an issue, recommendations were based on the clinical experience of the Working Group. These recommendations are indicated in the evidence tables as based on "Working Group Consensus". Algorithm Format the goal in developing the guideline for hypertension was not to repeat the guideline development process, but rather, to incorporate the information from several existing, national consensus, evidence-based guidelines into a format which would maximally facilitate clinical decision making. The use of the algorithm format was chosen because of the evidence that such a format improves data collection, diagnostic and therapeutic decision-making and changes patterns of resource use. This required incorporating multiple published guidelines into a single, unified document. Arrows connect the numbered boxes indicating the order in which the steps should be followed. Hexagons represent a decision point in the guideline, formulated as a question that can be answered Yes or No. A letter within a box of an algorithm refers the reader to the corresponding annotation. The annotations elaborate on the recommendations and statements that are found within each box of the algorithm. Included in the annotations are brief discussions that provide the underlying rationale and specific evidence tables. Annotations indicate whether each recommendation is based on scientific data or expert opinion. Systolic blood pressure as an independent predictor of mortality in the Hypertension Detection and Follow-up Program. Heart failure: evaluation and care of patients with leftventricular systolic dysfunction. Angiotensin-converting enzyme inhibitor-associated elevations in serum creatinine. Antihypertensive treatment and the course of established cerebral vascular disease. Prognostic value of systolic and diastolic blood pressure in treated hypertensive men. Randomised equivalent trial comparing three month and six month follow up of patients with hypertension by family practitioners. Effects of different blood-pressure-lowering regimens on major cardiovascular events: results of prospectively-designed overviews of randomized trials. Cardiovascular prognosis of "masked hypertension" detected by blood pressure self-measurement in elderly treated hypertensive patients. Epidemiologic association between dietary calcium intake and blood pressure: a meta-analysis of published data. Placebo-controlled study of lisinopril in congestive heart failure: a multicentre study. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Adherence to management of high blood pressure: Recommendations of the Canadian Coalition for High Blood Pressure Prevention and Control. Effect of vasodilator therapy on mortality in chronic congestive heart failure: Results of a Veterans Administration Cooperative Study. A randomized trial of the angiotensinreceptor blocker valsartan in chronic heart failure. Blood Pressure, antihypertensive drug treatment and the risks of stroke and of coronary artery disease. Part 2, Short-term reductions in blood pressure: Overview of randomised drug trials in their epidemiological context. Carvedilol inhibits clinical progression in patients with mild symptoms of heart failure. Consequences of intermittent treatment for hypertension: the case for medication compliance and persistence. Effects of beta-blocker therapy on mortality in patients with heart failure: a systematic overview of randomized controlled trials. Detection, adherence and control of hypertension for the prevention of stroke: a systematic review. Fosinopril attenuates clinical deterioration and improves exercise tolerance in patients with heart failure. Ann Epidemiol 2002; 12:587-595 Feldman R, Bacher M, Campbell N, Drover A, Chockalingam A. Treatment of isolated systolic hypertension is most effective in older patients with high-risk profile. The interaction of patient perception of overmedication with drug compliance and side effects. Overview of randomized trials of angiotensinconverting enzyme inhibitors on mortality and morbidity in patients with heart failure. Blood pressure response to changes in sodium and potassium intake: a metaregression analysis of randomized trials. Randomised trial of old and new antihypertensive drugs in elderly patients: cardiovascular mortality and morbidity the Swedish Trial in Old Patients with Hypertension-2 study. Aspirin for the primary prevention of cardiovascular events: a summary of the evidence for the U. Effect of beta-blockade on mortality in patients with heart failure: a metaanalysis of randomized clinical trials. Self-reported hypertension treatment practices among primary care physicians: blood pressure thresholds, drug choices, and the role of guidelines and evidence-based medicine. How much exercise is required to reduce blood pressure in essential hypertensives: a dose response study. To what extent do congestive heart failure patients in sinus rhythm benefit from digoxin therapy? Angiotensin receptor blockers in heart failure: meta-analysis of randomized controlled trials. Effects of low sodium diet versus high sodium diet on blood pressure, renin, aldosterone, catecholamines, cholesterols, and triglyceride (Cochrane Review). Aerobic exercise and resting blood pressure: a meta-analytic review of randomized, controlled trials. Prediction of coronary and cerebrovascular morbidity and mortality by direct continuous ambulatory blood pressure monitoring in essential hypertension. Efficacy and acceptability of perindopril in mild to moderate chronic congestive heart failure. Age-specific relevance of usual blood pressurevto vascular mortality: A meta-analysis of individual data for one million adults in 61vprospective studies. Comparison of agreement between different measures of blood pressure in primary care and daytime ambulatory blood pressure. Part 1, Prolonged differences in blood pressure: Prospective observational studies corrected for dilution bias. Effects of valsartan on morbidity and mortality in patients with heart failure not receiving angiotensin-converting enzyme inhibitors. Department of Veterans Affairs Cooperative Study Group on antihypertensive agents.


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Lifetime benefits and costs of intensive therapy as practiced in the Diabetes Control and Complications Trial. Dual-test monitoring of hyperglycemia using daily glucose and weekly fructosamine values. A prospective, randomized, multicentered controlled trial to compare the annual outcomes of patients with diabetes mellitus monitored with weekly fructosamine testing versus usual care: a 3-month interim analysis. The hospital and home use of a 30-second hand-held blood ketone meter: guidelines for clinical practice. Evaluation of a new handheld biosensor for point-of-care testing of whole blood hydroxybutyrate concentration. Treatment of diabetic ketoacidosis using normalization of blood 3-hydroxybutyrate concentration as the endpoint of emergency management: a randomized controlled study. Clinical utility of hydroxybutyrate determined by reflectance meter in the management of diabetic ketoacidosis. Direct measurement of 3- -hydroxy butyrate enhances the management of diabetic ketoacidosis in children and reduces time and costs of treatment. Bedside ketone determination in diabetic children with hyperglycemia and ketosis in the acute care setting. Accuracy of an electrochemical sensor for measuring capillary blood ketones by fingerstick samples during metabolic deterioration after continuous subcutaneous insulin infusion interruption in type 1 diabetic patients. Ketone bodies as markers for type 1 (insulin-dependent) diabetes and their value in the monitoring of diabetic control. Elevated plasma -hydroxybutyrate concentrations without ketonuria in healthy insulin-dependent diabetic patients. Monitoring therapy with insulin in ketoacidotic patients by quantifying 3hydroxybutyrate with a commercial kit. Serum -hydroxybutyrate measurement in patients with uncontrolled diabetes mellitus. American Association of Clinical Endocrinologists, American College of Endocrinology. European Society for Paediatric Endocrinology/Lawson Wilkins Pediatric Endocrine Society consensus statement on diabetic ketoacidosis in children and adolescents. The 2004 Canadian Hypertension Education Program recommendations for the management of hypertension, part I: blood pressure measurement, diagnosis and assessment of risk. Cross sectional longitudinal study of spot morning urine protein:creatinine ratio, 24 hour urine protein excretion rate, glomerular filtration rate, and end stage renal failure in chronic renal disease in patients without diabetes. Comparison of urinary albumin excretion rate in overnight urine and albumin creatinine ratio in spot urine in diabetic patients in general practice. Evaluation of a rapid screening test for microalbuminuria with a spot measurement of urine albumincreatinine ratio. An aid to the early detection and management of diabetic nephropathy: assessment of a new point of care microalbuminuria system in the diabetic clinic. The clinical application of a urine albumin:creatinine ratio point-of-care device. Microalbuminuria testing in diabetes: is a dipstick as effective as laboratory tests? Soonthornpun S, Thammakumpee N, Thamprasit A, Rattarasarn C, Leelawattana R, Setasuban W. The utility of conventional dipsticks for urinary protein for screening of microalbuminuria in diabetic patients. Screening for microalbuminuria in type 2 diabetic patients: the evaluation of a dipstick test in general practice. The use of semi-quantitative urine test-strip (Micral Test) for microalbuminuria screening in patients with diabetes mellitus. Performance of a reagent strip device for quantitation of the urine albumin: creatinine ratio in a point of care setting. Screening school children for albuminuria, proteinuria and occult blood with dipsticks. Testing for microalbuminuria in 2002: barriers to implementing current guidelines. Accuracy of the urinary albumin titrator stick "Micral-Test" in kidney-disease patients. Microalbuminuria as a marker of cardiovascular and renal risk in type 2 diabetes mellitus: a temporal perspective. Screening for microalbuminuria to prevent nephropathy in patients with diabetes: a systematic review of the evidence. Time-resolved fluorescence resonance energy transfer assay for point-of-care testing of urinary albumin. Increase in nocturnal blood pressure and progression to microalbuminuria in type 1 diabetes. High prevalence of immuno-unreactive intact albumin in urine of diabetic patients. Earlier detection of microalbuminuria in diabetic patients using a new urinary albumin assay. Differences in urinary albumin detected by four immunoassays and high-performance liquid chromatography. Generally, such testing is performed using urine as the sample and targets the more commonly abused substances. The purported flexibility and ease of use make these devices attractive for use in a variety of settings and by an equally varied range of users. As will be emphasized throughout this chapter, these devices are designed to screen for the presence of designated drugs or groups of drugs. The document will not address the broader issues or questions of urine drug screening; however, those interested may find some of the issues associated with such testing in the medical setting discussed in the National Academy of Clinical Biochemistry Emergency Toxicology Laboratory Medicine Practice Guidelines. After the initial questions were agreed upon, we found it necessary to perform a broad literature search to identify a sufficient number of papers for review. Pairs of members assessed the papers on the basis of the abstract to identify 100 manuscripts for full review. The amount of sample needed for testing ranges from a few drops of urine to 30 mL. Devices are available for the detection of a single drug or drug class, as well as for the detection of groups of drugs, i. As with laboratory-based methods, most are designed to detect drug metabolites instead of the parent drug. Following practices stemming from workplace drug testing, a positive result is obtained when the drug(s) or metabolite of interest is present at or above a designated concentration, i. The visual endpoint derived is dependent upon the technological approach and will be discussed shortly. Currently, there is only 1 commercially available system that provides a semiautomated assay and a printable report or record of the result(s). For other devices, the operator is responsible for all manipulations of the sample, reagent application, and timing, as well as interpretation and recording of the results, including quality-control indicators. Although the devices can be classified as those utilizing agglutination reactions, chromogenic antibodies, or fluorgenic or chromogenic drug-conjugates, it is more common to see the devices separated according to the visual indicator generated when drug is present at or above the designated cutoff. In other words, the absence of a line or color means the test result is positive, whereas the development of a line or color indicates the drug is below the threshold. At this time, there is 1 device that indicates the presence of the drug of interest with the appearance of a line. Freshly collected urine with no evidence of turbidity and sediment appears optimal 64 for these devices. Samples containing sediment or that are visibly turbid are poorly absorbed into the testing area (1, 2). For such samples, precentrifugation may be necessary for proper sample application (1, 2). In 1 study, poor absorption was shown to contribute to the occurrence of false-negative results (1).

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The main strength is that cystatin C is less dependent on age, gender, muscle mass, and liver function [34, 42]. They vary in their anatomical origin, physiological function, time of release after the onset of renal injury, kinetics, and distribution [24, 25] (Table 3, Fig. The availability of these new markers has allowed the detection of subtle changes in renal function before serum creatinine rises and the identification of patients with evidence of kidney injury without a change in serum creatinine, i. Of note, biomarker-positive, creatinine-negative patients appear to have a greater risk of complications, a longer stay in hospital and higher mortality compared to patients without a biomarker rise [38]. In critically ill patients, the most common causes are sepsis, heart failure, haemodynamic instability, hypovolaemia, and exposure to nephrotoxic substances [9]. Determining the aetiology is essential to guide management and potentially target and influence the disease process. Furthermore, adverse outcomes have been noted even when creatinine returned to baseline within 24 h [52]. Urinalysis, examination of the urinary sediment, and imaging studies should be performed as a minimum, with additional tests depending on the clinical presentation (Fig. These include: proteinuria) acute pyelonephritis (with pyuria/leucocyturia and nitrites in urine) interstitial nephritis (occasionally with eosinophiluria) It is important to consider the result of the urine dipstick alongside the clinical history and an evaluation of the patient. For instance, the presence of white blood cells is non-specific but may indicate an underlying infection or acute interstitial nephritis. Similarly, dipstick haematuria in a patient with an indwelling urinary catheter can have multiple aetiologies ranging from glomerulonephritis to simple trauma. They also detect haemoglobinuria from intravascular haemolysis as well as myoglobin from muscle breakdown. A urine dipstick positive for haemoglobin without red blood cell positivity suggests a possible diagnosis of rhabdomyolysis. It is recognised that the process is dynamic and that patients may move from one phase to another. When done properly, the presence of red Ostermann and Joannidis Critical Care (2016) 20:299 Page 8 of 13 Fig. In situations associated with transient hypovolaemia or hypoperfusion, healthy kidneys respond by increasing urine osmolarity and reducing sodium and/or urea or uric acid excretion. Ostermann and Joannidis Critical Care (2016) 20:299 Page 9 of 13 Table 4 Interpretation of urine microscopy findings Microscopy finding Epithelial cells Example Significance Normal Table 4 Interpretation of urine microscopy findings (Continued) Granular casts More significant renal disease "Muddy brown cast" Renal tubular cells Acute tubular injury Necrotic tubular cells aggregated with tamm horsfall protein indicating acute tubular injury Crystals Nondysmorphic red cells Non-glomerular bleeding from anywhere in the urinary tract Some crystals can be found in healthy individuals; "abnormal" crystals may indicate metabolic disorders or excreted medications Bacteria Dysmorphic red cells Glomerular disease, but can also be seen if urine sample is not fresh at time of microscopy Urinary tract infection; contamination Renal ultrasound Red cell casts Diagnostic of glomerular disease Leukocytes Up to 3 per high-power field = normal; >3 per high-power field = inflammation in urinary tract White cell casts Renal infection Hyaline casts Any type of renal disease Renal ultrasonography is useful for evaluating existing structural renal disease and diagnosing obstruction of the urinary collecting system. In patients with abdominal distension ultrasonography can be technically challenging, in which case other imaging studies will be necessary. The non-invasiveness, repeatability, and accessibility of these techniques appear promising, but broad clinical use is still limited by training requirements as well as uncertainty how to interpret the information obtained. Renal biopsy Renal biopsies are rarely performed in critically ill patients, mainly due to the perceived risk of bleeding complications and general lack of therapeutic consequences. However, a renal biopsy may offer information that is not available through other means and should be considered if underlying parenchymal or glomerular renal disease is suspected (Fig. Recent reports have suggested that transjugular renal biopsies may be safer than percutaneous or open techniques [78]. The interpretation of additional diagnostic investigations can be challenging, too. Dipstick haematuria is not uncommon in patients with an indwelling urinary catheter and most commonly due to simple trauma. Even more specialised tests, like autoimmune tests, have a higher risk of false-positive results in critically ill patients. Until more reliable tests are routinely used in clinical practice it is essential to interpret creatinine results and other diagnostic tests within the clinical context [80]. Several groups are developing optical measurement techniques using minimally invasive or non-invasive techniques that can quantify renal function independent of serum creatinine or urine output. In the past few years, significant progress has been made in using two-photon excitation fluorescence microscopy to study kidney function [82]. It is very likely that several of these approaches will enter clinical phase studies in the very near future. New imaging techniques may also be utilised, including cine phase-contrast magnetic resonance imaging or intravital multiphoton studies [83, 84]. However, given the complexity, financial costs, and need for patient transport, it is likely that they will remain research tools. The exact diagnostic investigations depend on the clinical context and should include routine baseline tests as well as more specific and novel tools. Raising awareness of acute kidney injury: a global perspective of a silent killer. Acute kidney injury network: report of an initiative to improve outcomes in acute kidney injury. Acute kidney injury after cardiac surgery according to Risk/Injury/Failure/Loss/Endstage, Acute Kidney Injury Network, and Kidney Disease: Improving Global Outcomes Classifications. Diagnosis of acute kidney injury: Kidney Disease Improving Global Outcomes criteria and beyond. Acute kidney injury in patients with acute lung injury: impact of fluid accumulation on classification of acute kidney injury and associated outcomes. Fluid accumulation, recognition and staging of acute kidney injury in critically-ill patients. Oliguria as predictive biomarker of acute kidney injury in critically ill patients. Activation of the renin-angiotensin system contributes significantly to the pathophysiology of oliguria in patients undergoing posterior spinal fusion. Oliguria and biomarkers of acute kidney injury: star struck lovers or strangers in the night? Detection of decreased glomerular filtration rate in intensive care units: serum cystatin C versus serum creatinine. Current use of biomarkers in acute kidney injury: report and summary of recommendations from the 10th Acute Dialysis Quality Initiative consensus conference. Biomarkers of renal injury and function: diagnostic, prognostic and therapeutic implications in heart failure. Discovery and validation of cell cycle arrest biomarkers in human acute kidney injury. The outcome of neutrophil gelatinase-associated lipocalinpositive subclinical acute kidney injury: a multicenter pooled analysis of prospective studies. Diagnosis of acute kidney injury using functional and injury biomarkers: workgroup statements from the tenth acute dialysis quality initiative consensus conference. Vanmassenhove J, Glorieux G, Lameire N, Hoste E, Dhondt A, Vanholder R, Van Biesen W. Influence of severity of illness on neutrophil gelatinaseassociated lipocalin performance as a marker of acute kidney injury: a prospective cohort study of patients with sepsis. Serum cystatin C, a new marker of glomerular filtration rate, is increased during malignant progression. Effect of corticosteroid therapy on serum cystatin C and beta2-microglobulin concentrations. Factors influencing serum cystatin C levels other than renal function and the impact on renal function measurement. Fluid resuscitation does not improve renal oxygenation during haemorrhagic shock in rats. Transient azotaemia is associated with a high risk of death in hospitalized patients. Acute kidney injury: prevention, detection and management of acute kidney injury up to the point of renal replacement therapy. A prospective evaluation of urine microscopy in septic and non-septic acute kidney injury. Light chain crystalline kidney disease: diagnostic urine microscopy as the "liquid kidney biopsy". Manual urine microscopy versus automated urine analyzer microscopy in patients with acute kidney injury. A systematic review of urinary findings in experimental septic acute renal failure. Significance of the fractional excretion of urea in the differential diagnosis of acute renal failure.


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