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Therefore it is recommended that the specialized instruments and software are provided by the company for the purpose of acceptance testing, and that the tests are carried out on-site by the company engineer, under supervision of the user. The user may chose to perform additional tests to confirm the operation of the equipment and may chose to use these results as a reference for future quality control. If necessary, the user should invite a competent expert to participate in the acceptance tests and the evaluation of the results. Warranty period the warranty period (usually one year) should be clearly defined in the purchasing documents. The warranty period is very useful in exposing possible failures of electronic components at an early stage. It is recommended that the warranty period should start only when the equipment has passed all acceptance tests. Equipment should be put into clinical use as soon as possible in order to optimize the warranty period. There must be a clear understanding between the supplier and the end user as to how the warranty period will be influenced if a major part of the system needs to be replaced during the warranty period. The company should perform regular services and preventative maintenance procedures during this period. Service contracts A service contract should be negotiated, to include labour and either no spare parts, spare parts excluding the crystal, or all spare parts. The price of the service contract usually varies between 2 and 10% of the purchase price of the imaging system. The supplier should make available a qualified person to perform preventative maintenance and servicing on the camera (proof of adequate training should be provided). In the event of system failure, the maximum response time of the service engineer should be specified (two hours is a typical figure). The maximum acceptable downtime per year should also be specified (10% of available working days is suggested). A penalty clause should be added to the contract if the supplier does not meet all the requirements. The supplier should supply a checklist of what will be performed during the services for preventative maintenance. The service engineer should leave on-site a record of all tests and checks performed. It is recommended that quality control tests such as those for uniformity and spatial resolution be performed before each service and repeated after completion, to evaluate the effectiveness of the service. General considerations the main imaging device in nuclear medicine is the gamma camera based on a sodium iodide detector, developed originally in 1958 by H. Although there are rectilinear scanners still in use, these will not be discussed. Multidetector systems are normally constructed using multiple gamma cameras that improve the efficiency of detection. Designs using multiple small detectors rather than conventional gamma cameras are also not in widespread use. The design of gamma cameras has improved dramatically over a long period, with current devices being very much digital systems rather than simply being interfaced to an acquisition computer. Over the years the performance of cameras has also improved; not only is their resolution, uniformity and count rate capability better but also, more importantly, their stability is improved. Although there have been various attempts to design specialized gamma camera systems for specific applications, in general the more successful designs are those that provide flexibility. In many centres, the camera is required for different applications and, at the time of purchase, it is often difficult to predict what the ultimate application may be. Provided this flexibility is maintained, a dual head system has the advantage of improved throughput, and the low likelihood of both heads having problems means that a single head can be available for continued operation, even when the second head is non-functioning. A dual head system also offers the possibility for dual photon imaging, as discussed elsewhere. It is this flexibility that has resulted in the dual head camera currently being the most popular system. Although more expensive than a single head system, the dual head system is cost effective in terms of both throughput and flexibility. The computer is now an integral part of any imaging system, and consideration of not only speed but also the range of available software, connectivity and ease of upgrade become important considerations. There has been a trend in recent years towards standard computer platforms that can keep abreast of developments more easily than the older manufacturer-specific systems. Even though these systems tend to lag behind the general release of systems software, they generally offer a wide range of available peripherals and general software (including free software). Although there is a wide selection of advanced clinical applications software, the ability to develop user defined applications, without the need for advanced programming skills, remains a requirement that is not always available. Confirmation of results arising from application software is the responsibility of the site concerned. Particular care needs to be taken to ensure that interpretation is correct for the population concerned (e. There are many accessories for gamma cameras, including some that reduce overall reliability. One example is automated collimator exchangers that do not permit manual override and therefore result in the system being inoperable in the event of malfunction. Although basic collimators have changed very little (except for construction), there is a range of specialized collimators now available including fanbeam and cone-beam collimators that provide improved efficiency as well as marginally improved resolution compared with that of parallel hole collimators. In the case of transmission sources, there is a range of available options with no single system acknowledged as clearly superior, and effectiveness of correction is dependent to some extent on the software supplied. For example, it is now common for manufacturers to offer iterative reconstruction software as an alternative to filtered back-projection. The system choice is normally based on the underlying camera unless there is very high priority for a specific acquisition (e. The use of such an approach enables comparison of bids, resulting in a possible scoring system that will assist in the decision making process. The above tests should be done in addition to the following planar gamma camera tests. Minimum quality control requirements for gamma cameras Routine quality control is an essential requirement for any nuclear medicine practice in order to ensure that equipment operation remains optimal. Quality control is commonly, but wrongly, viewed as a difficult and time consuming chore and, for this reason, is frequently neglected. This section provides guidelines for minimum quality control based on the Australian and New Zealand Society of Nuclear Medicine recommendations and is compatible with other recommendations. The guidelines are intended to provide a very basic practical approach to gamma camera quality control, requiring very little specialized equipment or expertise. It is therefore recommended that these guidelines be adopted by all nuclear medicine practices. The minimum quality control tests are intended to detect problems before they have an impact on clinical patient studies. Further tests may be required to trace the cause of a problem and to ensure that the equipment is performing properly after service or adjustment. Exact quality control procedures vary between manufacturers and models, making it impractical to provide detailed quality control procedures covering all equipment. In order to make quality control procedures as simple as possible, the following is a suggested list of the minimum test equipment required: (a) Cobalt-57 sheet source this source is recommended for high count extrinsic uniformity checks and the collection of uniformity correction floods. It is preferable to water filled flood tanks, which may introduce non-uniformities due to poor mixing, bulging 118 4. On some systems, a water filled flood tank may also be required to calibrate the system for non-99mTc radionuclides such as 67Ga. The finest bars should be small enough to test the intrinsic resolution of the system (i. It is imperative that quality control procedures be carried out in a consistent manner (i. Proper record keeping greatly facilitates detection of gradual deterioration of performance over an extended period of time.

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Value of low dose combination treatment with blood pressure lowering drugs: analysis of 354 randomised trials. Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. In patients who do not respond to or do not tolerate treatment with 2 to 3 medications or medication combinations, additional trials of treatment tend to be ineffective or poorly tolerated. Some patients may become disillusioned and lost to follow-up, whereas others will identify an alternative healthcare provider, including nontraditional healers, or will try popular home remedies. Working with this more demanding subset requires provider expertise, patience, and a mechanism to respond efficiently and sensitively to concerns as they arise. In this setting, team-based care (see Section 12) may be effective, encouraging coupling of nonpharmacological and pharmacological treatments, while improving access to and communication with care providers. Consideration of patient comorbidities, lifestyle, and preferences may suggest better tolerance or greater effect from one class of medication versus other classes. For example, if hyponatremia is present, it would be important to avoid or stop thiazide diuretic therapy. If hypokalemia is present, primary or secondary aldosteronism should be excluded, after which one should consider a potassium-sparing agent, such as spironolactone, eplerenone, triamterene, or amiloride. In addition, reducing dietary sodium intake will diminish urinary potassium losses. Follow-Up After Initiating Antihypertensive Drug Therapy References that support the recommendation are summarized in Online Data Supplement 28. Adults initiating a new or adjusted drug regimen for hypertension should have a follow-up evaluation of adherence and response to treatment at I B-R monthly intervals until control is achieved (1-3). Systematic approaches to follow-up have been shown to improve hypertension control and can be adapted and incorporated into clinical practices according to local needs and resource availability (see Section 8. Two self-management interventions to improve hypertension control: a randomized trial. Home blood pressure management and improved blood pressure control: results from a randomized controlled trial. Hypertension in Patients With Comorbidities Certain comorbidities may affect clinical decision-making in hypertension. The present guideline does not address the recommendations for treatment of hypertension occurring with acute coronary syndromes. Atenolol is not as effective as other antihypertensive drugs in the treatment of hypertension (23). Systolic blood pressure reduction and risk of cardiovascular disease and mortality: a systematic review and network meta-analysis. Clinical events in high-risk hypertensive patients randomly assigned to calcium channel blocker versus angiotensin-converting enzyme inhibitor in the antihypertensive and lipid-lowering treatment to prevent heart attack trial. Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial Collaborative Research Group. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. Clinical efficacy of verapamil alone and combined with propranolol in treating patients with chronic stable angina pectoris. Beta Blockade after myocardial infarction: systematic review and meta regression analysis. A systematic review of selective and non-selective beta blockers for prevention of vascular events in patients with acute coronary syndrome or heart failure. Effects of the cardioselective beta-adrenergic receptor blocking agent metoprolol in angina pectoris. Developed in collaboration with the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension. Heart Failure References that support the recommendation are summarized in Online Data Supplement 33. In the Cardiovascular Health Study (5) and the Health, Aging and Body Composition Study (6), 11. Effects of intensive blood pressure lowering on the progression of chronic kidney disease: a systematic review and meta-analysis. High body fatness, but not low fat-free mass, predicts disability in older men and women: the Cardiovascular Health Study. The loss of skeletal muscle strength, mass, and quality in older adults: the health, aging and body composition study. The Cardiovascular Health Study and the Health, Ageing and Body Composition Study. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Heart Failure With Reduced Ejection Fraction References that support recommendations are summarized in Online Data Supplement 34. Lifestyle modification, such as weight loss and sodium reduction, may serve as adjunctive measures to help these agents work better. Diltiazem increases late-onset congestive heart failure in postinfarction patients with early reduction in ejection fraction. The Adverse Experience Committee; and the Multicenter Diltiazem Postinfarction Research Group. Normal left ventricular ejection fraction in older persons with congestive heart failure. Comparison of incidences of congestive heart failure in older African-Americans, Hispanics, and whites. Outcome of congestive heart failure in elderly persons: influence of left ventricular systolic function. Congestive heart failure in subjects with normal versus reduced left ventricular ejection fraction: prevalence and mortality in a population-based cohort. Heart Failure With Preserved Ejection Fraction References that support recommendations are summarized in Online Data Supplements 35 and 36. Conversely, the use of inappropriately high doses of diuretics can lead to volume contraction, which can increase the risk of hypotension and renal insufficiency. A shared decision-making discussion, with the patient influenced by clinician judgment, should drive the ultimate choice of antihypertensive agents. Effect of propranolol versus no propranolol on total mortality plus nonfatal myocardial infarction in older patients with prior myocardial infarction, congestive heart failure, and left ventricular ejection fraction > or = 40% treated with diuretics plus angiotensin-converting enzyme inhibitors. Trends in prevalence and outcome of heart failure with preserved ejection fraction. Relation of disease pathogenesis and risk factors to heart failure with preserved or reduced ejection fraction: insights from the Framingham Heart Study of the National Heart, Lung, and Blood Institute. Heart failure with preserved ejection fraction: persistent diagnosis, therapeutic enigma. Exaggerated hypertensive response to exercise in patients with diastolic heart failure. Heart failure with preserved and reduced left ventricular ejection fraction in the antihypertensive and lipid-lowering treatment to prevent heart attack trial. Effect of phosphodiesterase-5 inhibition on exercise capacity and clinical status in heart failure with preserved ejection fraction: a randomized clinical trial. Chronic Kidney Disease References that support recommendations are summarized in Online Data Supplements 37 and 38 and Systematic Review Report. Hypertension may occur as a result of kidney disease, yet the presence of hypertension may also accelerate further kidney injury; therefore, treatment is an important means to prevent further kidney functional decline. Likewise, intensive therapy was beneficial even in those 75 years of age with frailty or the slowest gait speed. The effects of dietary protein restriction and blood-pressure control on the progression of chronic renal disease. Albuminuria assessed from first-morning-void urine samples versus 24-hour urine collections as a predictor of cardiovascular morbidity and mortality. Comparison of different measures of urinary protein excretion for prediction of renal events. The effects of amlodipine and enalapril on renal function in adults with hypertension and nondiabetic nephropathies: a 3-year, randomized, multicenter, double-blind, placebo-controlled study. Effect of angiotensin-converting enzyme inhibitors on the progression of nondiabetic renal disease: a meta-analysis of randomized trials. Chronic Kidney Disease (Partial Update): Early Identification and Management of Chronic Kidney Disease in Adults in Primary and Secondary Care.

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The views expressed in this guideline do not necessarily reflect those of the Ministry of Health and Long-Term Care. Any reference throughout the document to specific pharmaceutical products as examples does not imply endorsement of any of these products. The document needs to be reviewed and applied, based on the specific needs of the organization or practice setting/environment, as well as the needs and wishes of the client. Guidelines should not be applied in a "cookbook" fashion but used as a tool to assist in decision making for individualized client care, as well as ensuring that appropriate structures and supports are in place to provide the best possible care. Nurses, other healthcare professionals and administrators who are leading and facilitating practice changes will find this document valuable for the development of policies, procedures, protocols, educational programs, assessment and documentation tools, etc. It is recommended that this nursing best practice guideline be used as a resource tool. Nurses providing direct client care will benefit from reviewing the recommendations, the evidence in support of the recommendations and the process that was used to develop the guidelines. However, it is highly recommended that practice settings/environments adapt these guidelines in formats that would be user-friendly for daily use. This guideline has some suggested formats for such local adaptation and tailoring. Organizations wishing to use the guideline may decide to do so in a number of ways: Assess current nursing and healthcare practices using the recommendations in the guideline. Systematically develop a plan to implement the recommendations using associated tools and resources. Nurses will be knowledgeable regarding the process involved in the diagnosis of hypertension. Nurses will educate clients about self/home blood pressure monitoring techniques and appropriate equipment to assist in potential diagnosis and the monitoring of hypertension. Nurses will educate clients on their target blood pressure and the importance of achieving and maintaining this target. Nurses will assess for and educate clients about dietary risk factors as part of management of hypertension, in collaboration with dietitians and other members of the healthcare team. Nurses will counsel clients with hypertension to limit their dietary intake of sodium to the recommended quantity of 65-100 mmol/day, in collaboration with dietitians and other members of the healthcare team. Nurses will counsel clients, in collaboration with the healthcare team, to engage in moderate intensity dynamic exercise to be carried out for 30-60 minutes, 4 to 7 times a week. Nurses will be knowledgeable about the classes of medications that may be prescribed for clients diagnosed with hypertension. Nurses will provide education regarding the pharmacological management of hypertension, in collaboration with physicians and pharmacists. Nurses will provide the information needed for clients with hypertension to make educated choices related to their treatment plan. Nurses will ensure that clients who miss appointments receive follow-up telephone calls in order to keep them in care. Nurses will advocate that clients who are on antihypertensive treatment receive appropriate follow-up, in collaboration with the healthcare team. Nurses will document and share comprehensive information regarding hypertension management with the client and healthcare team. Knowledge and skills should include, at minimum: Pathophysiology of hypertension; Maximizing opportunities for detection; Facilitating diagnosis; Assessing and monitoring clients with hypertension; Providing appropriate client/family education; Supporting lifestyle changes; Promoting the empowerment of the individual; and Documentation and communication with the client and other members of the healthcare team. Healthcare organizations will establish care delivery systems that allow for training in adherence management, as well as a means of accurately assessing adherence and those factors that contribute to it. Healthcare organizations will develop key indicators and outcome measurements that will allow them to monitor: the implementation of the guidelines, the impact of these guidelines on optimizing quality client care, efficiencies, or cost effectiveness achieved. Nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. Opportunities for reflection on personal and organizational experience in implementing guidelines. This guideline was developed by a panel of nurses, conducting its work independent of any bias or influence from the. This best practice guideline focuses on assisting nurses working in diverse practice settings in the management of hypertension. Improving the management of high blood pressure by doctors, nurses and pharmacists. The development of a guideline on the management of high blood pressure by nurses was identified as an appropriate strategy to facilitate nursing interventions in hypertensive management as a component of the first stream of this initiative. The goal of this document is to provide nurses with recommendations, based on the best available evidence, related to nursing interventions for high blood pressure detection, client assessment and development of a collaborative treatment plan, promotion of adherence and ongoing follow-up. Nurses working in partnership with the interdisciplinary health care team, clients and their families, have an important role in detection and management of hypertension. This guideline focuses on: the care of adults 18 years of age and older (including the older adult over 80); the detection of high blood pressure; nursing assessment and interventions for those who have a diagnosis of hypertension. This is not meant to exclude the pediatric client, but children have special assessment needs related to developmental stages that are beyond the scope of this guideline. This guideline also does not address hypertension in adults related to: pregnancy, transient hypertension, pulmonary hypertension, endocrine hypertension, or hypertension related to secondary causes (i. This guideline contains recommendations for Registered Nurses and Registered Practical Nurses on best nursing practices in the care of adults with hypertension. It is intended for nurses who are not necessarily experts in management of hypertension, who work in a variety of practice settings, including both primary care and secondary prevention. It is acknowledged that the individual competencies of nurses varies 18 Nursing Best Practice Guideline between nurses and across categories of nursing professionals and are based on knowledge, skills, attitudes, critical analysis and decision making which are enhanced over time by experience and education. It is acknowledged that effective healthcare depends on a coordinated interdisciplinary approach incorporating ongoing communication between health professionals and clients/families. The panel discussed the purpose of their work, and came to consensus on the scope of the best practice guideline. Subsequently, a search of the literature for clinical practice guidelines, systematic reviews, relevant research articles and websites was conducted. Several international guidelines have reviewed the evidence related to hypertension, and it was determined that a critical appraisal of these existing guidelines would serve as a "foundation" for guideline development. A total of 12 clinical practice guidelines on the topic of hypertension were identified that met the following initial inclusion criteria: published in English; developed in 1999 or later; strictly on the topic of hypertension; evidence-based; and the guideline is available and accessible for retrieval. The seventh report of the Joint National Committee: Prevention, detection, evaluation and treatment of high blood pressure. The panel members divided into subgroups to undergo specific activities using the short listed guidelines, evidence summaries, studies, and other literature for the purpose of drafting recommendations for nursing interventions. This process resulted in the development of practice, education and organization and policy recommendations. The panel members as a whole reviewed the first draft of recommendations, discussed gaps, reviewed the evidence and came to consensus on a final set of recommendations. Stakeholders represented various healthcare professional groups, clients and families, as well as professional associations. External stakeholders were provided with specific questions for comment, as well as the opportunity to give overall feedback and general impressions. The term adherence is intended to be non judgemental, a statement of fact rather than of blame of the prescriber, client or treatment. Blood pressure: Blood pressure is the product of the amount of blood pumped by the heart each minute (cardiac output) and the degree of dilation or constriction of the arterioles (systemic vascular resistance). It is a complex variable involving mechanisms that influence cardiac output, systemic vascular resistance, and blood volume. Hypertension is caused by one or several abnormalities in the function of these mechanisms or the failure of other factors to compensate for these malfunctioning mechanisms (Woods, Motzer & Bridges, 2005). Systolic Pressure: Systolic pressure represents the pressure when the heart contracts and forces blood into the blood vessels.

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The subcommittees work together to review the hypertension scientific literature from clinical trials, epidemiology, and behavioral science. In many instances, the principal investigator of the larger studies has presented the information directly to the Coordinating Committee. It was published in an electronic format on May 14, 2003, and in print on May 21, 2003. The writing teams also met by teleconference and used electronic communications to develop the report. At its meetings, the Executive Committee used a modified nominal group process14 to identify and resolve issues. In addition, 33 national hypertension leaders reviewed and commented on the document. Methods 7 Lifetime Risk of Hypertension Hypertension is an increasingly important medical and public health issue. Age-specific relevance of usual blood pressure to vascular mortality: A meta-analysis of individual data for one million adults in 61 prospective studies. If the systolic and diastolic pressure readings for a subject were in different categories, the higher of the two categories was used. This revision reflects the fact that the approach to the management of the former two groups is similar (table 2). The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Rather, it is a designation chosen to identify individuals at high risk of developing hypertension, so that both patients and clinicians are alerted to this risk and encouraged to intervene and prevent or delay the disease from developing. The treatment goal for individuals with hypertension and no other compelling conditions is <140/90 mmHg (see Compelling Indications). The presence of each additional risk factor compounds the risk from hypertension as illustrated in figure 12. Management of these other risk factors is essential and should follow the established guidelines for controlling these coexisting problems that contribute to overall cardiovascular risk. The prevalence of systolic hypertension increases with age, and above 50 years of age, systolic hypertension represents the most common form of hypertension. A survey of primary care physicians indicated that three-fourths of them failed to initiate Figure 13. Difference in coronary heart disease prediction between systolic and diastolic blood pressure as a function of age 1. A number of important causal factors for hypertension have been identified, including excess body weight; excess dietary sodium intake; reduced physical activity; inadequate intake of fruits, vegetables, and potassium; and excess alcohol intake. Systolic blood pressure distributions Because the lifetime risk of developing hypertension is very high (figure 8), a public health strategy, which complements the hypertension treatment strategy, is warranted. The probability of success increases as interventional strategies more aptly address the diversity of racial, ethnic, cultural, linguistic, religious, and social factors in the delivery of medical services. Community service organizations can promote the prevention of hypertension by providing culturally sensitive educational messages and lifestyle support services and by establishing cardiovascular risk factor screening and referral programs. Prevention of Hypertension: Public Health Challenges 17 C a l i b r at i o n, M a i n t e n a n c e, a n d U s e o f B lo o d P r e s s u r e D e v i c e s the potential of mercury spillage contaminating the environment has led to the decreased use or elimination of mercury in sphygmomanometers as well as in thermometers. The equipment- whether aneroid, mercury, or electronic-should be regularly inspected and validated. The operator should be trained and regularly retrained in the standardized technique, and the patient must be properly prepared and positioned. Caffeine, exercise, and smoking should be avoided for at least 30 minutes prior to measurement. An appropriately sized cuff (cuff bladder encircling at least 80 percent of the arm) should be used to ensure accuracy. Followup of patients with various stages of hypertension is recommended as shown in table 4. Recommendations for followup based on initial blood pressure measurements for adults without acute end organ damage Initial Blood Pressure (mmHg)* Followup Recommended Normal Prehypertension Stage 1 Hypertension Stage 2 Hypertension Recheck in 2 years Recheck in 1 year Confirm within 2 months Evaluate or refer to source of care within 1 month. Patient evaluation is made through medical history, physical examination, routine laboratory tests, and other diagnostic procedures. Data from epidemiological studies and clinical trials have demonstrated that elevations in resting heart rate and reduced heart-rate variability are associated with higher cardiovascular risk. In the Framingham Heart Study, an average resting heart rate of 83 beats per minute was associated with a substantially higher risk of death from a cardiovascular event than the risk associated with lower heart rate levels. Increased 20 the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure Table 7. Screening tests for particular forms of identifiable hypertension are shown in table 8. Pheochromocytoma should be suspected in patients with labile hypertension or with paroxysms of hypertension accompanied by headache, palpitations, pallor, and perspiration. Examples of clues from the laboratory tests include unprovoked hypokalemia (primary aldosteronism), hypercalcemia (hyperparathyroidism), and elevated creatinine or abnormal Table 8. Appropriate investigations should be conducted when there is a high index of suspicion of an identifiable cause. These can generally be distinguished by the clinical setting and additional testing. For example, a renal ultrasound is useful in diagnosing polycystic kidney disease. While renal artery angiography remains the gold standard for identifying the anatomy of the renal artery, it is not recommend for diagnosis alone because of the risk associated with the procedure. At the time of intervention, an arteriogram will be performed using limited contrast to confirm the stenosis and identify the anatomy of the renal artery. Genetic association studies have identified polymorphisms in several candidate genes (e. Goals of Therapy the ultimate public health goal of antihypertensive therapy is to reduce cardiovascular and renal morbidity and mortality. Consume a diet rich in fruits, vegetables, and lowfat dairy products with a reduced content of saturated and total fat. Engage in regular aerobic physical activity such as brisk walking (at least 30 min per day, most days of the week). The effects of implementing these modifications are dose and time dependent, and could be greater for some individuals. Tables 10 and 11 provide a list of the commonly used antihypertensive agents, and their usual dose range and frequency of administration. More than two-thirds of hypertensive individuals cannot be controlled on one drug and will require two or more antihypertensive agents selected from different drug classes. Oral antihypertensive drugs* (continued) Class Drug (Trade Name) Usual Dose Range in mg/Day 12. Rationale for Recommendation of Thiazide-Type Diuretics as Preferred Initial Agent In trials comparing diuretics with other classes of antihypertensive agents, diuretics have been virtually unsurpassed in preventing the cardiovascular complications of hypertension. Higher doses have been shown to add little additional antihypertensive efficacy, and are associated with more hypokalemia and other adverse effects. Some reports have described an increased degree of sexual dysfunction when thiazide diuretics (particularly at high doses) are used. Thiazide diuretics are less expensive than other antihypertensive drugs, although as members of other classes of drugs have become available in generic form, their cost has been reduced. Selection of one of these other agents as initial therapy is recommended when a diuretic cannot be used or when a compelling indication is present that requires the use of a specific drug, as listed in table 12.

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Buccal misoprostol compared with synthetic osmotic cervical dilator before surgical abortion: A randomized controlled trial. A randomized trial of laminaria tents versus vaginal misoprostol for cervical ripening in first trimester surgical abortion. A randomized controlled trial of laminaria, oral misoprostol, and vaginal misoprostol before abortion. Complications of first-trimester abortion by vacuum aspiration after cervical preparation with and without misoprostol: A multicentre randomised trial. A randomised comparison between sublingual, oral and vaginal route of misoprostol for pre-abortion cervical ripening in first-trimester pregnancy termination under local anesthesia. Ultrasound can be performed in addition but is not a replacement for bimanual examination before intrauterine procedures. Medical regimens for abortion and postabortion care change based on the gestational age or uterine size. Techniques for vacuum aspiration and dilatation and evacuation, including instrument choice and need for cervical preparation, depend on accurate knowledge of uterine size. Determining uterine position the position of the uterus in the pelvis, orientation of the fundus to the cervix and firmness of the uterus are best determined with bimanual examination. Knowledge of uterine position assists providers in avoiding complications, particularly perforation, during procedures (Chen, Lai, Lee, & Leong, 1995; Mittal & Misra, 1985; Nathanson, 1972). Uterine perforation following medical termination of pregnancy by vacuum aspiration. Sending products of conception for routine histopathology evaluation is not recommended. Presence of products of conception on visual inspection confirms that the pregnancy was intrauterine and is consistent with successful abortion (Westfall, Sophocles, Burggraf, & Ellis, 1998). If products of conception are not seen, a woman should not leave the facility until plans are made for follow-up. Immediate examination of the products of conception can also expedite the diagnosis of ectopic pregnancy and decrease related morbidity and mortality (Goldstein, Danon, & Watson, 1994). If no pregnancy tissue is visualized and ectopic pregnancy is suspected, follow local guidelines to rule out ectopic pregnancy. In cases where abnormal pathology is suspected, such as molar pregnancy, histopathology may be used in addition to visual inspection. Studies show that sending products of conception for routine histopathology exam does not affect clinical outcomes and increases the cost of abortion (Heath, Chadwick, Cooke, Manek, & MacKenzie, 2000; Paul, Lackie, Mitchell, Rogers, & Fox, 2002). An updated protocol for abortion surveillance with ultrasound and immediate pathology. Should tissue from pregnancy termination and uterine evacuation routinely be examined histologically? Step 2: cleaning Disassemble aspirator and adaptor (if used) and clean with warm water and detergent using a soft brush. Step 3: Sterilization or high-level diSinfection All aspirators and adaptors must be sterilized or high-level disinfected after use. Clinical Updates in Reproductive Health March 2018 61 Step 4: Storage Aspirators and adapters may be dried, the O-ring lubricated and the device reassembled and stored in a clean dry area until use. The aspirator does not need to remain high-level disinfected or sterilized at the time of use and can be placed in a clean area or stored according to local standards. Between 10 and 13 weeks, the success rate of mifepristone combined with misoprostol is over 95%, with a continuing pregnancy rate of less than 2% and complication rate of 3%. A combined regimen of mifepristone and misoprostol is recommended for medical abortion; where mifepristone is not available, the misoprostol-only regimen may be used. A misoprostol-only regimen has lower success rates of about 85%, with continuing pregnancy rates of 3-10% and complication rates of 1-4% up to 13 weeks gestation. A 2015 systematic review reported data from 20 studies that included a total of 33,846 women undergoing medical abortion with mifepristone and buccal misoprostol through 70 days gestation (Chen & Creinin, 2015). One prospective cohort study has examined mifepristone combined with vaginal misoprostol from 63-70 days gestation, finding a success rate of 95% (Gouk et al. Between 10 and 13 weeks gestation only one available study, a retrospective cohort study of 1,076 women, has used the currently recommended regimen of 200mg mifepristone followed 36-48 hours later by misoprostol (800mcg vaginally or 600mcg sublingually), and then repeated doses of 400mcg misoprostol vaginally or sublingually every three hours for two additional doses (Hamoda, Ashok, Flett, & Templeton, 2005). The success rate for this Clinical Updates in Reproductive Health March 2018 63 regimen was 95. A smaller prospective cohort study which included 254 women used a similar regimen and reported a success rate of 91. Safety Three large cohort studies, including a total of 260,256 women, have reported complications observed during medical abortion with mifepristone and misoprostol up to nine weeks gestation (Cleland et al. These studies found rates of incomplete abortion requiring uterine aspiration of 2. Between 10 and 13 weeks, reported rates of uterine aspiration for any reason range from 4-8% (Hamoda et al. A large retrospective cohort study of 11,319 first-trimester medical abortions evaluated all complications from abortions provided in the state of California in the United States from 2009-2010 (Upadhyay et al. Researchers assessed complications arising at the time of the abortion, as well as complications diagnosed when patients sought additional care from sites other than the site where the abortion was provided, such as emergency departments. The overall rate of complications during the six weeks following medical abortion was 5. Large retrospective case series documenting success and complication rates are not available. Disparate regimens, gestational age ranges, timeframes to measure abortion success and reporting of complications makes comparison of success and complication rates across studies of misoprostol-only medical abortion difficult. Smaller studies using similar regimens have reported success rates of 92% for gestations up to eight weeks (Fekih, 2010), 89-91% up to nine weeks (Salakos et al. In general, higher rates of success with misoprostol-only regimens are associated with lower gestational ages (von Hertzen et al. Safety the most commonly reported complications with misoprostol-only medical abortion are incomplete and failed abortion requiring aspiration. In studies that used the recommended misoprostol-only regimen or similar regimens, the rate of aspiration for any reason ranges from 12-17%, with ongoing pregnancy rates of 3-10% (Carbonell et al. Other complications are infrequently reported: Bleeding requiring aspiration occurs in 1-4% of women (Velazco et al. Comparison of misoprostol-only and combined mifepristone-misoprostol regimens for home-based early medical abortion in Tunisia and Vietnam. Efficacy and safety of mifepristone-buccal misoprostol for early medical abortion in an Australian setting. A prospective randomized, double-blinded, placebo-controlled trial comparing mifepristone and vaginal misoprostol to vaginal misoprostol alone for elective termination of pregnancy. First-trimester pregnancy termination with 800mcg of vaginal misoprostol every 12 h. The European Journal of Contraception and Reproductive Health Care, 10(4), 249-254. Early pregnancy termination with vaginal misoprostol before and after 42 days gestation. Exposure to misoprostol carries a small increased risk of malformations if the woman has an ongoing pregnancy and decides not to terminate. Women with an ongoing pregnancy after using misoprostol should be counseled about the risk if they choose to carry the pregnancy to term. Exposure to certain medications, infections, radiation or drugs of abuse during embryonic or fetal development may result in an increased risk of malformations if the pregnancy continues. Mifepristone Data on continuing pregnancy after mifepristone exposure without misoprostol are limited. The largest prospective study of 46 women continuing a pregnancy after mifepristone resulted in eight miscarriages and, in the pregnancies that continued, two major malformations (5. Neither malformation was thought to be related to mifepristone exposure but may have been a result of other medical conditions (Bernard et al. Although not clearly established, the proposed mechanism is vascular disruption from uterine contractions leading to disordered fetal development (Gonzalez et al. Clinical Updates in Reproductive Health March 2018 67 A systematic review of four case-control studies with 4,899 cases of congenital anomalies and 5,742 controls showed an increased rate of misoprostol exposure in cases with anomalies (da Silva Dal Pizzol, et al. In a cohort of 183 women exposed to misoprostol during the first 12 weeks of pregnancy, the major malformation rate was 5.

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High-dose daunorubicin for acute nonlymphcytic leukemia: correlation of response and toxicity with pharmacokinetics and intracellular daunorubicin reductase activity. Deferasirox: uncertain future following renal failure fatalities, agranulocytosis and other toxicities. Efficacy and safety of deferasirox doses of >30 mg/kg per d in patients with transfusion-dependent anaemia and iron overload. Long-term safety and efficacy of deferasirox (Exjade) for up to 5 years in transfusional iron-overloaded patients with sickle cell disease. Pharmacokinetics, metabolism, and disposition of deferasirox in b-thalassemic patients with transfusion-dependent iron overload who are at pharmacokinetic steady state. Deferasirox: a review of its use in the management of transfusional chronic iron overload. Acute interstitial nephritis secondary to deferasirox causing acute renal injury needing short-term dialysis. Pharmacokinetics of desferrioxamine and of its iron and aluminum chelates in patients on haemodialysis. Pharmacokinetics of desferrioxamine and of its iron and aluminum chelates in patients on peritoneal dialysis. Pharmacokinetics and renal elimination of desferrioxamine and ferrioxamine in healthy subjects and patients with haemochromatosis. Acute visual and auditory neurotoxicity in patients with end-stage renal disease receiving desferrioxamine. Ocular toxicity after a single intravenous dose of desferrioxamine in 2 hemodialyzed patients. Aluminum removal with hemodialysis, hemofiltration and charcoal hemoperfusion in uremic patients after desferrioxamine infusion: a comparison of efficiency. The rate of infusion should not exceed 15 mg/kg/h for the first 1,000 mg administered. Pharmacokinetics and pharmacodynamics of the tetracyclines including glycylcyclines. Plasma demeclocycline levels and nephrotoxicity: correlation in hyponatremic cirrhotic patients. Under such conditions, lower than usual total doses are indicated, and if therapy is prolonged, serum level determinations of the drug may be advisable. Results of a double-blind, multicenter trial comparing the efficacy of desirudin (Revasc) with that of unfractionated heparin in patients having a total hip replacement. A comparison of recombinant hirudin with a low-molecular-weight heparin to prevent thromboembolic complications after total hip replacement. Antithrombotic effects of recombinant hirudin in experimental angioplasty and intravascular thrombolysis. Effect of renal impairment on the pharmacokinetics and pharmacodynamics of desirudin. Distinct effects of recombinant desulfatohirudin (Revasc) and heparin on plasma levels of fibrinopeptide A and prothrombin fragment F1. Recombinant hirudin for unstable angina pectoris: a multicenter, randomized angiographic trial. Pharmacokinetics and renal excretion of desmopressin after intravenous administration to healthy subjects and renally impaired patients. The pharmacokinetics of 400 mg of oral desmopressin in elderly patients with nocturia, and the correlation between the absorption of desmopressin and clinical effect. Pharmacokinetics, pharmacodynamics, long-term efficacy and safety of oral 1-deamino-8-d-arginine vasopressin in adult patients with central diabetes insipidus. Pharmacokinetics and antidiuretic effect of high-dose desmopressin in patients with chronic renal failure. Low-dose oral desmopressin for nocturnal polyuria in patients with benign prostatic hyperplasia: a double-blind, placebo-controlled, randomized study. Antidiuretic effect and pharmacokinetics of oral 1-deamino-8-d-arginine vasopressin. Pharmacological and clinical profile of newer antidepressants: implications for the treatment of elderly patients. Introduction of a composite parameter to the pharmacokinetics of venlafaxine and its active O-desmethyl metabolite. The effects of desvenlafaxine and paroxetine on the pharmacokinetics of the cytochrome P450 2D6 substrate desipramine in healthy adults. The pharmacokinetics and safety of desvenlafaxine in subjects with chronic renal impairment. Desvenlafaxine: a new serotonin-norepinephrine reuptake inhibitor for the treatment of adults with major depressive disorder. A comparison of the pharmacokinetics of venlafaxine extended release and desvenlafaxine succinate in healthy subjects [abstract]. Feasibility and pharmacokinetic study of infusional dexrazoxane and dose-intensive doxorubicin administered concurrently over 96 h for the treatment of advanced malignancies. Dexrazoxane: a review of its use for cardioprotection during anthracycline chemotherapy. Pharmacokinetics of (+)-1,2-di(3,5-dioxopiperazin-i-yl) propane intravenous infusions in adult cancer patients. Dexrazoxane significantly impairs the induction of doxorubicin resistance in the human leukaemia line, K562. Phase I trial of 96-hour continuous infusion of dexrazoxane in patients with advanced malignancies. Interaction of dexrazoxane with red blood cells and hemoglobin alters pharmacokinetics of doxorubicin. A comparison of the clearance of urographic contrast medium (sodium diatrizoate) by peritoneal and haemodialysis. Acute tubular necrosis in a renal transplant recipient: complication from drip-infusion excretory urography. Acute renal failure following intravenous urography in patients with long-standing diabetes and azotemia. Nonionic contrast media are less nephrotoxic than ionic contrast media to rat renal cortical slices. All other indications-dose adjustment not required Azotemia and dehydration Anuria Alternative adjustment: All patients Urography and large-dose vascular procedures are contraindicated. Effects of parenteral diclofenac sodium on upper gastrointestinal motility after food in man. Pharmacokinetics of diclofenac and five metabolites after single doses in healthy volunteers and after repeated doses in patients. Effects of celecoxib and diclofenac on blood pressure, renal function, and vasoactive prostanoids in young and elderly subjects. Diclofenac does not decrease renal blood flow or glomerular filtration in elderly patients undergoing orthopedic surgery. Effects of arachidonic acid metabolic inhibitors on hypoxia/reoxygenationinduced renal cell injury. Renal tolerability of three commonly employed non-steroidal anti-inflammatory drugs in elderly patients with osteoarthritis. Reversible membranous nephropathy associated with the use of nonsteroidal antiinflammatory drugs. Acute renal failure associated with diclofenac treatment in an elderly woman [letter]. Diclofenac sodium: a reappraisal of its pharmacodynamic and pharmacokinetic properties, and therapeutic efficacy. Proximal tubular dysfunction associated with tenofovir and didanosine causing Fanconi syndrome and diabetes insipidus: a report of 3 cases. The effect of food administration on the bioavailability of didanosine from a chewable tablet formulation.

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In all cases, management of comorbid conditions must be integrated into the overall care of patients with chronic kidney disease. Factors associated with progression of kidney disease are discussed in Guideline 13. In diseases characterized by a quantifiable marker of damage-for example, albuminuria in diabetic kidney disease-progression, stability, or regression can be estimated by change in the marker. For most diseases, however, quantitative relationships between changes in markers and progression have not been established. Complications due to disorders in other organ systems are associated with worse outcomes. These include maintenance of the filtration barrier for plasma proteins (abnormalities include albuminuria and proteinuria), reabsorption or secretion of water or specific solutes (abnormalities include tubular syndromes), and various endocrine functions (erythropoietin deficiency causes anemia, parathyroid hormone excess causes bone disease, and vitamin D deficiency causes bone disease). Prevention and treatment of complications of chronic kidney disease includes specific therapies related to the pathogenesis of complications-for example, erythropoietin for anemia and vitamin D for bone disease. Treatment and prevention of cardiovascular disease in chronic kidney disease includes risk factor reduction as well as specific therapies for cardiovascular disease and should begin as early as possible. Patients require education and advance preparation to cope with the stresses of kidney failure, to choose 72 Part 4. All patients should probably be instructed to preserve suitable veins for possible future vascular access construction. The indications for initiation of kidney replacement therapy are based on the level of kidney function and presence of signs and symptoms of uremia. Patients with chronic kidney disease are prescribed a large number of medications. In addition, patients may take other medications, such as over-the-counter medications, ``non-traditional' medications, vitamins and supplements, herbs, and drugs of abuse. A thorough review of the medication list and all other medications should be conducted at each visit. Drugs with potentially adverse effects on kidney function or complications of decreased kidney function should be discontinued if possible. Because of possible alterations in volume of distribution, protein binding, drug elimination, and drug-drug interactions in chronic kidney disease, therapeutic drug monitoring should be performed, if possible. A large amount of information is available to providers in texts, manuals, and databases for handheld computers. Interpretation may be facilitated by the similarity between the classification of levels of kidney function proposed in this guideline and the recommendations for pharmacokinetic studies of drugs in patients with decreased kidney function made by the Food and Drug Administration84 (on the Internet,. Healthy people make choices that could ultimately shorten their lives, such as smoking, drinking or eating too much, not exercising, missing prescribed medications, and failing to get an annual physical. Those with chronic health conditions requiring lifestyle changes and clinician-initiated visits are more likely to be noncompliant. Definition and Classification 73 Because the terminology ``noncompliance' or ``nonadherence' often leads to prejudice and negative stereotyping, it is recommended that ``self-management behaviors' be substituted. Frequently the primary care provider will make the diagnosis of chronic kidney disease. Referral to a nephrologist or other specialist for consultation or co-management should be made after diagnosis under the following circumstances: a clinical action plan cannot be prepared based on the stage of the disease, the prescribed evaluation of the patient cannot be carried out, or the recommended treatment cannot be carried out. These activities may not be possible either because the appropriate tools are not available or because the primary care physician does not have the time or information needed to do so. Subsequent guidelines will elaborate on the concepts in this guideline, but it is beyond the scope of these guidelines to provide specific instructions for evaluation and management. The ultimate goal is to develop specific guidelines for each action at each stage of disease. In principle, prevention of adverse outcomes of chronic kidney disease could be facilitated by evaluating individuals with risk factors, to enable earlier detection, and by risk factor reduction in individuals without chronic kidney disease, to prevent or slow the development of chronic kidney disease. In principle, the relationship between the risk factor and the outcome may be either causal or non-causal. Causal risk factors are determinants of the outcome, and successful intervention to reduce exposure to them would improve outcomes. Non-causal risk factors may be associated with the outcome through confounding or reverse causation. Interventions to reduce exposure to non-causal risk factors would not necessarily improve outcomes. A useful classification of risk factors has been used in cardiovascular disease epidemiology100 and is shown in Table 38. In addition, because it can be difficult to detect the onset of chronic kidney disease, some risk factors for faster progression may appear to be to susceptibility or initiation factors (Table 39). Note that progression factors may be associated with progression either because initial damage cannot be resolved or because damage is ongoing. In addition, numerous factors have been shown to be associated with worse outcomes in patients with kidney failure, (such as inadequate dialysis dose, temporary vascular access, anemia, and low serum albumin concentration). Textbooks and reviews list a large number of potential risk factors for chronic kidney disease. The difficulty of detecting the early stages of chronic kidney disease makes it difficult to determine whether the risk factors so far identified relate more to susceptibility, initiation, or progression. Table 40 contains a partial list of clinical and sociodemographic factors that have been implicated as susceptibility or initiation factors. For some of these factors (for example, diabetes), interventions (like strict glycemic control) have been proven to lower the risk of developing chronic kidney disease (Category I, Table 38). The prevalence of individuals at increased risk for development of chronic kidney disease has not been studied systematically. However, some idea of the magnitude of the problem can be obtained by reviewing data from recent publications (Table 42). It is beyond the scope of these guidelines to provide specific instructions for screening. However, the list of individuals at increased risk for chronic kidney disease includes a large fraction of the adult population (Table 42). Thus, it is important to carefully consider the definition of individuals at increased risk and methods for testing them. Suggestions (based on opinion) for evaluation of individuals at increased risk for chronic kidney disease are provided in Part 9. However, as indicated in Table 42, a large number of individuals without high blood pressure and diabetes may also be at increased risk. Thus, it will be important to test a larger population than currently targeted, which would increase the cost of health care. The increased health care costs that would follow implementation of a screening program for chronic kidney disease may well require a more solid base of evidence than is currently available. The Work Group recommends development of a clinical practice guideline focused on this issue in order to develop specific recommendations for evaluat- 78 Part 4. In the past, universal screening was not recommended because of the low prevalence of chronic kidney disease and the lack of treatments to improve outcomes. Data provided in these guidelines suggests that the prevalence of earlier stages of chronic kidney disease is higher than previously known and that earlier detection and treatment to prevent or delay the loss of kidney function and development of cardiovascular disease in chronic kidney disease. If sufficient information is not available to assess the value of testing individuals at increased risk, or of universal screening, the Work Group suggests that research on evaluation programs should be conducted. As described in Appendix 1, Table 151, the Work Group evaluated studies according to accepted methods for evaluation of diagnostic tests. To provide a more comprehensive review, the Work Group attempted to integrate the systematic review of specific questions with existing guidelines and recommendations. If a substance in stable concentration in the plasma is physiologically inert, freely filtered at the glomerulus, and neither secreted, reabsorbed, synthesized, nor metabolized by the kidney, the amount of that substance filtered at the glomerulus is equal to the amount excreted in the urine. The amount of excreted inulin equals the urine inulin concentration (Uin) multiplied by the urine flow rate (V, volume excreted per unit time). The inulin clearance, in mL/min, refers to that volume of plasma per unit time that is cleared of inulin by renal excretion. Inulin clearance measurements in healthy, hydrated young adults (adjusted to a standard body surface area of 1. Glomerular filtration rate in the infant differs quantitatively from that in older children and adults. These factors extend the study time necessary for techniques relying on equilibration of the marker substance and monitoring of its plasma disappearance rate. Rationale for Alternative Measures the classic method of inulin clearance requires an intravenous infusion and timed urine collections over a period of several hours making it costly and cumbersome.

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Data processing and image interpretation the flow of activity in the spinal subarachnoid space is fast and smooth. A low activity segment is noted in the thoracic region due to a thickening of the spinal cord. The activity reaches the basal cisterna after one to three hours, and then enters the sylvian and interhemispheric fissures. The lateral views display the cisterna magna, quadrigemina, interpeduncularis, suprasellar and pontis. The distribution of activity on both sides is symmetrical in the anterior and posterior views. After 24 hours, activity is distributed around the convexity of the brain, especially along the superior sagittal sinus. If any sign of lateral ventricles appears on the image, then communicating hydrocephalus, with normal pressure or obstructive in nature, is suspected. Leakage or fistula is diagnosed if any activity is dispersed outside the outline of the subarachnoid space. To facilitate detection, the patient should lie sitting with the head in hyperflexion. Precautions the radiopharmaceutical must meet all quality requirements for intrathecal use. Introduction Renal radionuclide studies are commonly used procedures, particularly in paediatrics. The goal is to obtain reliable functional and structural information in a non-invasive way and to provide the clinician with both diagnostic and prognostic information. The tubules are even less mature than the glomeruli at birth, but maturation of the tubules is more rapid. Renal immaturity in neonates reduces to some extent the utility of radionuclide studies during the first months of life. In infants, the relatively large extravascular space gives a low plasma concentration of any freely diffusible injected substance. Oxidation of the product reduces tubular reabsorption and increases urinary excretion, so care should be taken to prevent oxidation. A child should be cushioned comfortably against the camera face, and in an inclined or supine position. An infant should be cushioned and supported in place with Velcro strapping, lying supine on the face of the camera, which has been covered by a protective sheet. In adults, the acquisition of 500 000 counts each of the posterior, anterior, left and right posterior oblique views is recommended. Measurement Relative function is determined from the background subtracted renal activities in the posterior view according to right or left/(right + left). In the case of displaced kidneys, the geometric mean of the background subtracted renal activities in the posterior and anterior views is used. Interpretation Normally the kidney contours are smooth and rounded with a contrast between the outer cortical part and the less active medial portion of the kidneys. These kinds of defect are seen in acute pyelonephritis and may either heal or develop into permanent lesions. Imaging at the time of urinary tract infection may show defects due to renal infection. Imaging three, or preferably six, months later will show whether these defects have healed or left scars. Scarring may be found without demonstrable vesicoureteric reflux, and reflux may be present without demonstrable scarring. Pitfalls In the case of a unilateral duplex kidney with normal parenchyma, the duplicated kidney may correspond to more than 55% of the total function. Pelvic retention, in the case of hydronephrosis, may cause an artefactually high differential function. Principle the uptake by the kidneys of a tracer substance, its transit through the nephrons and its excretion into the pelvis and then through the urethers into the bladder are evaluated. The tracer should be non-reabsorbable and can be filtered by the glomeruli, excreted by the renal tubules or a combination of both. The amount filtered depends on the degree of protein binding of the agent in the plasma. The amount secreted depends on the affinity of the transport sites in the proximal tubules for the agent. On the basis of renographic curves, descriptive indices or measurements related to renal physiology may be obtained (e. Clinical indications Renography can be used for any of the following purposes: (a) (b) (c) (d) (e) (f) (g) (h) (i) Measurement of the contribution of each kidney to global renal function. Evaluation of obstructive nephropathy and obstructing uropathy (for definitions see Section 5. Determination of the presence of renovascular disorder as a cause of hypertension. Thus, liver uptake is not dependent on renal function but on the impurities contained. It is actively excreted by the tubules and weakly protein bound with approximately 6% glomerular filtration. It requires a medium energy collimator and gives a high radiation dose to the kidneys in the case of obstruction. It is also recommended as an agent of choice but is less easily available commercially. A low energy, parallel hole collimator with high resolution is preferred for the most widely used 99mTc agents. Procedure the procedure should be explained to the patient or parents before entering the gamma camera room. The bladder should be emptied before entering the camera room and the time should be noted. In infants unable to void on demand, bladder emptying will be spontaneous so catheterization is not usually needed. The patient should void again at the end of the test, and the volume and time noted to give a measure of the urine flow. This is the most comfortable position and allows free gravitational drainage of the pelvis and easy observation of any tendency for the kidneys to descend. In children, the study is performed more easily if the patient is lying in the supine position on the couch. An image of the pelvis and bladder before and after micturition and/or after five minutes in the upright position to ensure gravitational drainage is recommended in the event of pelvic retention at the end of the study. The injection should be less than 1 mL in volume and either given rapidly or pushed by a bolus of saline through a three way stopcock. The injection should be given in one single continuous movement of the syringe plunger. The use of frame times greater than 15 s reduces the temporal resolution of the study so that the sharpness of the peak of the renogram and the quality of the analysis can be impaired. Interpretation A holistic approach to interpretation should be made combining images, renograms, numerical results and interventions (see below). A report should contain the demographic data, the name of the test, type and activity of the injected radiopharmaceutical, any interventions and any patient reactions (e. It should also include a description of the images and curves, the numerical data, a separate conclusion and a separate recommendation or clinical advice when appropriate. A description of the images should consider relative renal size, cortical or parenchymal defects and retention of activity in the parenchyma or pelvis.