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Background Clients receiving PrEP (HIV Pre-Exposure Prophylaxis) require renal function (estimated Glomerular Filtration Rate (eGFR)) monitoring as detailed in BASHH/BHIVA guidelines. Annual monitoring is required for individuals < 40 with normal baseline eGFR and no risk factors for kidney disease. Our busy urban sexual health clinic lacked a structured system for eGFR monitoring, with concern clients were being tested unnecessarily or not at all. Method A retrospective review was conducted of all clients under 40 years who received PrEP between June and November 2020. eGFR results and additional tests performed without clinical justification were extracted from records in the year preceding the issue of each PrEP prescription. The number of unnecessary repeat eGFRs within 12 months was recorded. Results 199 clients were identified of whom 186 (93.5%) had eGFR checked in the year prior to issuing PrEP. 13 clients (6.5%) therefore had inadequate eGFR monitoring whilst continuing to take PrEP. Of those tested, 55 (29.6%) had eGFR re-checked within a year without clinical justification with a total of 69 unnecessary tests performed. This equates to £345 expenditure on tests, six hours of clinical time administering results and overinvestigation of clients with minor fluctuations in eGFR. We implemented a new pathway for eGFR testing, including a visible alert on each client's record allowing clinical staff to immediately see when the eGFR was last checked, and when the next is due. Conclusion This study identified both under- and over-testing of eGFR for clients taking PrEP. Whilst it is vital that eGFR testing is not missed, over-testing wastes clinical and financial resources which are at a premium in an era of budgetary constraints and reduced appointment availability due to COVID- 19. As the number of clients taking PrEP increases, it is important for all services to ensure robust and efficient methods of eGFR monitoring..

The purpose of this review is to highlight the major advances of pediatric and neonatal acute kidney injury (AKI) research over the last 5 years with particular interest in describing renal physiology, the definition of AKI, risk factors, epidemiology, interventions, and outcomes. The utilization of standardized definitions of AKI has revolutionized our understanding of the incidence and impact of AKI. This has culminated in the seminal Assessment of Worldwide Acute Kidney Injury, Renal Angina and Epidemiology in critically ill children (AWARE), and Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates (AWAKEN) publications in pediatric and neonatal AKI, respectively. These studies have clearly shown an independent association of AKI with mortality in critically ill children and neonates. Recent work aimed at the prevention of AKI has demonstrated that nephrotoxic medication-induced AKI occurs commonly and can be prevented with protocolized renal function monitoring. This review also highlights advances in the early identification of patients at risk for the development of AKI via scoring systems (renal angina index), functional tests (furosemide stress test), or novel biomarkers. Furthermore, fluid overload has clearly been shown to impact outcomes in those with the most severe forms of AKI requiring renal replacement therapy. Recent single-center studies have highlighted that children with AKI are at increased risk of chronic kidney disease. The incidence and adverse impact of AKI on outcomes across critically ill pediatric and neonatal populations have been clearly established The importance of fluid overload in children with severe AKI requiring renal replacement therapy is clear. Children with AKI are at increased risk of chronic kidney disease and require long-term outpatient follow-up. As the impact of AKI has become clear, efforts have shifted to prevention of nephrotoxic-induced AKI, early identification, risk stratification (renal angina), and the development of novel biomarkers.

Introduction: Renal function testing should be performed prior to initiating medicines that require dose adjustment in renal impairment, with ongoing monitoring in continued use, particularly in older people. There is little evidence regarding the extent to which renal function monitoring is performed in older Australians dispensed medicines requiring renal function monitoring. Objective: The aim of this study was to determine the extent of renal function testing in older people dispensed medicines requiring renal function monitoring. Methods: A retrospective analysis of administrative claims data from the Australian Government Department of Veterans’ Affairs was conducted for people aged 65 years or older who were dispensed one or more medicines requiring renal function monitoring, from 1 June 2019 to 30 September 2019, to investigate the proportion of people with a claim for a pathology test that included creatinine levels in the 6–12 months before or after dispensing of a medicine requiring renal function monitoring. Results: There were 100,113 people who were dispensed at least one medicine requiring renal function monitoring during the study period, of whom 15% had a history of renal impairment and 16% had diabetes mellitus. Sixty-one percent had a claim for a test in the prior 6 months; this increased to 80% of participants with a claim for a test in the prior 12 months. The rate of claims for testing was lower in aged care facility residents compared with people living in the community (54% vs 62% in the previous 6 months; p < 0.001), and was higher in people with diabetes (75% vs 58%; p < 0.001), history of renal impairment (91% vs 59%; p < 0.001) or heart failure (77% vs 60%; p < 0.001) compared with those without these conditions. Conclusion: Medicines that require renal function monitoring are commonly used in older Australians, and while the majority have claims for tests that include renal function, some are missing out. Refereed/Peer-reviewed

BackgroundThe GMC PRACtiCe study identified a 1 in 20 error rate in prescriptions issued in general practice and identified a need for further training in prescribing. As a result, an e-Learning prescribing package was designed and launched to healthcare professionals through the Royal College of General Practitioners in January 2014.AimThis part of the study explored the longer-term impact on prescribing knowledge, attitudes and behaviours of practitioners completing the eLearning prescribing package.MethodOn completion of the e-Learning package, participants were asked to indicate their willingness to be contacted for a telephone interview. Semi-structured interviews were conducted which were audio recorded, transcribed verbatim and analysed using thematic analysis, aided by NVivo. Interviewees were invited to enter a prize draw to win Stockley’s Drug Interaction textbook (provided courtesy of the Royal Pharmaceutical Society).ResultsOf the 120 participants who expressed an interest in being followed up for interview, seven prescribers were interviewed in 2014 and 2015. Reasons for completing the course were explored, and interviewees gave examples of changes made to their prescribing practice as a result of completing the e-Learning. This included the adoption of specific strategies to enhance safe practice, and enacting enhanced vigilance in key areas such as renal function monitoring. Some changes to the course content and presentation were also recommended.ConclusionThese interviews have highlighted the potential for using e-Learning for prescribing training and to achieve long-term changes in prescribing practice. However, further work is needed to generate substantive evidence of its impact on prescribing.

The second most common cause of hospitalization due to adverse drug reactions in the UK is renal dysfunction due to diuretics, particularly in patients with heart failure, where diuretic therapy is a mainstay of treatment regimens. Therefore, the optimal frequency for monitoring renal function in these patients is an important consideration for preventing renal failure and hospitalization. This review looks at the current evidence for optimal monitoring practices of renal function in patients with heart failure according to national and international guidelines on the management of heart failure (AHA/NICE/ESC/SIGN). Current guidance of renal function monitoring is in large part based on expert opinion, with a lack of clinical studies that have specifically evaluated the optimal frequency of renal function monitoring in patients with heart failure. Furthermore, there is variability between guidelines, and recommendations are typically nonspecific. Safer prescribing of diuretics in combination with other antiheart failure treatments requires better evidence for frequency of renal function monitoring. We suggest developing more personalized monitoring rather than from the current medication-based guidance. Such flexible clinical guidelines could be implemented using intelligent clinical decision support systems. Personalized renal function monitoring would be more effective in preventing renal decline, rather than reacting to it.

The purpose of this European Heart Rhythm Association survey was to assess the attitude, level of education, and knowledge concerning oral anticoagulants (OACs) among patients with atrial fibrillation (AF) taking vitamin K antagonists (VKAs), non-VKA oral anticoagulants (NOACs) or antiplatelets. A total of 1147 patients with AF [mean age 66 ± 13 years, 529 (45%) women] from 8 selected European countries responded to this survey. The overall use of OACs and antiplatelets was 77 and 15.3%, respectively. Of the patients taking OACs, 67% were on VKAs, 33% on NOACs, and 17.9% on a combination of OACs and antiplatelets. Among patients on VKAs, 91% correctly stated the target international normalized ratio (INR) level. The proportion of patients on VKA medication who were aware that monthly INR monitoring was required for this treatment and the proportion of patients on NOAC who knew that renal function monitoring at least annually was mandatory for NOACs was 76 and 21%, respectively. An indirect estimation of compliance indicated that 14.5% of patients temporarily discontinued the treatment, and 26.5% of patients reported having missed at least one dose. The survey shows that there is room for improvement regarding education and adherence of patients taking OACs, particularly regarding monitoring requirements for NOACs.

BACKGROUND: The efficacy of sodium-glucose co-transporter 2 inhibitors (iSGLT) decrease with decreasing glomerular filtration rate. The summary of products’ characteristics recommends restriction in the use of iSGLT to patients with creatinine clearance (CrCl) >60 ml/min/1.73 m(2) and treatment should be suspended if CrCl 30). At the beginning of treatment 62.7% IC 95% (49.1%–75%) had CrCl >60 mL/min/1.73 m(2). 89.5%, 95% CI: 79.2% to 96. 2% patients followed renal function monitoring recommendations. Six patients had not correct monitoring, three patients did not have any follow-up and 3 patients had ClCr

Background Residential aged care is a complex and challenging clinical setting where medication errors continue to occur despite efforts to improve medication safety. No studies have sought to review and synthesize coronial investigations into medication-related deaths in Australian residential aged care facilities (RACFs). Objective To review coronial investigations into medication-related deaths in Australian RACFs. Methods A national review of medication-related deaths between July 2000 and July 2013 reported to Australian Coroners was performed. Data were extracted from the National Coronial Information System and errors categorized according to stages of the medication management cycle. Results The database search identified thirty coronial investigations into deaths. Single medication classes were implicated in 22 deaths; including opioids (n = 7), antipsychotics (n = 4) and antidepressants (n = 3). Eight deaths resulted from two or more medication classes. Thirteen deaths reported stages of medication errors, including administration (n = 9) and monitoring (n = 4). Coroners made recommendations following three deaths; including education and training on dose administration aids, regulation of personal care workers, and protocol-based renal function monitoring for residents taking digoxin. Conclusions Deaths involving high-risk medications occurred primarily at the stages of administration and monitoring. Few investigations resulted in specific recommendations, however it is unknown whether these were implemented.

A prototype medical device for monitoring kidney function by transdermal measurement of the clearance rate of the exogenous fluorescent tracer agent MB-102 (administered intravenously) was developed. Verification of the device with an in vitro protocol is described. The expected renal clearance of the agent was mimicked by preparing a dilution series of MB-102 in the presence of a scattering agent. The slope of a linear fit to the logarithm of fluorescence intensity as a function of dilution step agreed with predictions within 5%, a level of accuracy that would be adequate in assessment of GFR to prevent misdiagnosis of kidney disease. Transdermal measurement was validated using a rat model. A two-compartment pharmacokinetic dependence was observed, with equilibration of the fluorescent agent between the vascular space into which it was injected and the extracellular space into which it subsequently diffused. The best observed signal-to-noise ratios were about 150, allowing determination of the renal clearance time with 5% precision using a 10-min fitting window. Based on the verification and validation methods for transdermal fluorescence detection described herein, the instrument has been approved by the FDA for a first-in-human clinical study, and a first transdermal clearance curve in a human is presented herein.

Background 5-Amino salicylate (5-ASA) medications may rarely be associated with a significant decline in renal function and interstitial nephritis. British Society of Gastroenterology guidelines advise regular renal function monitoring for patients taking these drugs. Aim To assess whether gastroenterologists in Kent were following best practice guidelines regarding the monitoring of their patients on 5-ASA therapy. Methods Using longitudinal community and regional pathology databases for the Kent population, our renal unit regularly screens a total population of 300 000 for evidence of renal disease. The data extracted are analysed using an automated computerised system to identify patients requiring intervention for kidney disease. All patients taking 5-ASA medication were identified from a population of 300 000. The pathology database was studied to identify the patients on 5-ASA treatment and whether they had had renal function tests. Results 800 adult patients were identified taking 5-ASA therapy. 612 patients received 5-ASAs for 3 months or more, and these were included in the final analysis. 293 patients had no renal function checks while on treatment. 79 patients had renal function tests less than once every 4 years and 36 patients once every 2–4 years. 204 patients had renal function measurements in 50% or more of years of treatment, of whom 116 were checked every year. Some patients were started on treatment with abnormal results at baseline and some with identified kidney disease continued on their 5-ASAs. Conclusions The majority of patients receiving 5-ASA compounds do not have regular renal function monitoring. Clinicians are failing to follow best practice guidelines.

Background Acute kidney injury (AKI) might complicate antihypertensive therapy. In The Netherlands, general practitioner clinical practice guidelines provide clear recommendations on monitoring of renal function to minimize this risk. Our objective was to investigate how day-to-day clinical practice corresponds to the guidelines. Methods We conducted a retrospective cohort study in a dynamic population, using data on > 9,000 adults that was retrieved from the Integrated Primary Care Information database. We investigated whether serum creatinine (SCR) was measured within 30 and 365 days after the start of (combined) use of a diuretic, an angiotensin-converting enzyme inhibitor, and/or angiotensin receptor blocker. We also investigated the association between calendar year, sex, type of therapy, risk factors for AKI and practice and SCR measurement. Results Of 6,593 subjects who met the study criteria for single drug therapy, SCR was measured in 1,233 subjects within 30 days and in 3,896 subjects within 365 days. For combined drug therapy recipients (n = 2,497), these were 545 and 1,687, respectively. Associated cumulative probabilities were 19 % and 66 % with single drug therapy, and 22 % and 74 % with combined drug therapy. Significant differences were observed between practices. SCR measurement was associated with other characteristics, except for sex. Within 365 days, SCR increased > 30 % of baseline in 103 subjects (1.6 %) after the start of single drug therapy, and in 85 (3.4 %) subjects who initiated combined drug therapy. In the majority (> 70 %) of these subjects, this did not result in subsequent monitoring or adjustment of antihypertensive treatment. Conclusion Results from this study suggest that, on average, renal function is not monitored as strictly as recommended by relevant clinical practice guidelines.

The value of urinary cytology in the diagnosis of different pathological conditions in renal transplantation is particularly important. Manual microscopic urinalysis is a high-volume procedure that currently requires significant labour. Objective: To automate the sediment evaluation and to make this more accurate using the Iris Diagnostics Automated Urine Microscopy Analyzer (iQ200). Our goal was to compare the manual and automated microscopic data to apply iQ200 in renal function monitoring. Method: The iQ200 uses digital imaging and Auto Analyte Recognition software to classify urine constituents into 12 analyte categories and quantitatively report. Results: We determined cut-off values of urine particles in every category, which correlated well with manual microscopic results. The iQ200 was more sensitive for pathological casts than manual microscopic analysis. iQ200 helped the operator to differentiate between isomorphic and dismorphic erythrocytes and between lymphocytes and granulocytes, too. Every pathological constituent could be recognized, which is very important for early recognition of renal impairment, graft rejection and urinary tract infection. Conclusions: The iQ200 system automatically classifies 12 particles, significantly reducing the need for additional sample preparation, manual microscopic review achieving a high degree of standardization in urinalysis.

Toxicity from accidental and intentional ingestion of yellow phosphorus, ubiquitously present in fireworks and rodenticides, has recently become more frequent. Gastrointestinal, renal, neurologic, and cardiovascular manifestations are common, with mortality of 23 per cent to 73 per cent. Reports of haematological abnormalities are rare. We report only the second case of severe neutropenia secondary to selective myelosuppression in a 14-year-old girl following intentional ingestion of yellow phosphorus. Leucocyte counts recovered spontaneously without further complications. Our case indicates that, besides hepatic and renal function monitoring, physicians should meticulously monitor blood counts in such cases for early detection of marrow suppression. Further studies are required to elucidate the complex mechanisms and significance of this unusual toxicity of yellow phosphorus.

Children with non-renal solid organ transplants are surviving longer, but outcome is complicated by CKD. Accurate and frequent renal function monitoring is imperative to recognize and institute measures early to reverse, prevent, or arrest progression. This study of 59 children determined the accuracy (P30), bias, sensitivity and specificity between measured renal function by NM-GFR, and estimated GFR by three formulas: Filler (serum cystatin C), mSchwartz (serum creatinine), and CKiD (serum cystatin C, creatinine, urea, and height). Mean GFR by all formulas differed significantly from NM-GFR. Filler and mSchwartz formulas significantly increased the proportion of patients with GFR ≥ 90 mL/min/1.73 m(2) (CKD stage 1) while decreasing those with GFR 60-89 mL/min/1.73 m(2) (CKD stage 2). All formulas overestimated GFR. CKiD showed the highest P30 and lowest bias (79.7%; 6.9 mL/min/1.73 m(2) ) followed by Filler (67.7%; 19.9 mL/min/1.73 m(2) ) and Schwartz (57.6%; 26.8 mL/min/1.73 m(2) ) for all GFR values. All formulas performed best with GFR ≥ 90 mL/min/1.73 m(2) , but CKiD was the only formula to achieve 91.1% accuracy. All formulas showed high sensitivities, but low specificities at NM-GFR cutoff at 90. Thus, GFR estimated by CKiD followed by Filler formula is an adequate method to monitor renal function closely and frequently in these children.

Mineralocorticoid receptor antagonists (MRA's) have been shown to be effective in patients with HFREF while their role in patients with HFPEF remains controversial. Despite a class one indication in both the ESC and AHA/ACC heart failure guidelines in patients with HFREF MRA's remain underused, in large part due to the fear of hyperkalaemia and renal dysfunction. While hyperkalaemia is a potential risk of MRA's, their use when potassium and renal function monitoring is properly carried out is minimal compared with their benefits in appropriate patients. New nonsteroidal MRA's and new potassium binding polymers currently under development hold the promise of further reducing the risks of hyperkalaemia while allowing higher doses of MRA's. They have been shown to overcome diuretic resistance and to potentially extend their benefits to patients with acute decompensated heart failure and those with chronic renal disease. While we await the results of studies with these new agents; application of current guidelines recommended therapies, including MRA's hold the best promise to further reduce cardiovascular mortality, hospitalisations for heart failure, and therefore, health care costs in patients with heart failure.

Local delivery of antibiotics by a degradable carrier has the potential for high local antibiotic levels and avoids systemic toxicity. Intravenous access, renal function monitoring, and subsequent surgical removal may not be required when degradable local delivery modalities are used. This study examined the in vivo elution of gentamicin from processed bovine collagen (type I) in 66 adult White rabbits. Collagen impregnated with gentamicin (3 mg/kg) was implanted into the vastus lateralis, and data were collected from 15 minutes to 28 days after implantation. Local tissue biopsies were taken a minimum of 2 mm from the implantation site. The gentamicin was released into the local tissue and averaged more than 3,800 micrograms/ml during the initial 4 hours after implantation. Local levels fell to 6.90 +/- 5.22 micrograms/ml at 24 hours and subsequently were 2.70 +/- 1.75 micrograms/ml or more through day 28. Serum levels reached an average peak of 4.04 +/- 1.75 micrograms/ml at 5 hours after implantation, decreased after the initial 24 hours, and subsequently were less than 0.41 +/- 0.20 microgram/ml through day 28. Collagen impregnated with gentamicin proved to be an effective degradable carrier of gentamicin in the healthy rabbit; it provided local tissue concentrations above the minimum inhibitory concentration and serum concentrations below levels associated with systemic toxicity for 28 days after implantation.

International audience; Background and aim: 5-Aminosalicylates (ASA) are widely used in inflammatory bowel disease (IBD). Nephrotoxicity has been described in some IBD patients treated with 5-ASA. Whether physicians managing these patients are monitoring renal function in daily practice is unknown. The aims of this paper were to investigate how private gastroenterologists monitor renal function and manage renal failure in IBD patients treated with oral 5-ASA therapy.Methods: This was a web-based cross sectional national survey which was conducted among private gastroenterologists.Results: A total of 249 practitioners completed the survey. Eighty two percent (n = 205) of responders declared that they always monitor renal function. The respondents monitored twice a year Glomerular Filtration Rate (eGFR) using Modification of Diet in Renal Disease (MDRD) [90% (n = 225)] and Creatinine Clearance (CCr) using a 24-hour urine collection [51% (n = 126)]. Blood electrolytes, 24-hour urinary protein rate and dipsticks are performed by 41%, 39% and 22% of practitioners, respectively. Before oral 5-ASA initiation, 59% (n = 148) of respondents screen for renal failure. In case of elevated serum creatinine, a nephrologist's opinion is asked by 80% (n = 200) of responders and by 76% (n = 189) of respondents before treatment initiation.Conclusions: Most gastroenterologists are monitoring renal function once or twice a year in IBD patients on 5-ASA. Less than two thirds of them screen for renal failure before treatment initiation. MDRD is mainly used, but a wide range of parameters is evaluated.

The purpose of this European Heart Rhythm Association Survey was to assess the attitude, level of education and knowledge concerning oral anticoagulants (OAC) among atrial fibrillation (AF) patients taking blood thinners including vitamin K antagonists (VKAs), non-vitamin K antagonist oral anticoagulants (NOACs) or antiplatelets. The study included 1147 AF patients (mean age 66 ± 13 years, 529 females, 45%) from 8 selected European countries. The overall use of anticoagulants and/or antiplatelets in these patient cohorts were 77% and 15.3%, respectively. Of the patients taking anticoagulants, 67% were on VKAs, 33% on NOACs and 17.9% on a combination of OACs and antiplatelets. The proportion of patients on NOAC who knew that at least an annual renal function monitoring was mandatory for NOACs was 21%. 14.5% of patients temporarily discontinued the treatment, and 26.5% of patients declared having missed at least one dose. The survey shows that there is room for improvement regarding education and adherence of patients taking OACs, particularly regarding monitoring requirements for NOACs.

We are grateful to the Journal for highlighting the important issue of epidermal growth factor receptor (eGFR) monitoring in psychiatric patients prescribed lithium.[1][1] We recently carried out an audit of renal function monitoring across Camden and Islington NHS Foundation Trust. The aim was to

After having built and tested an expert system for renal function monitoring, the authors developed a knowledge representation formalism that is being used as a formal method to generate and verify new and unknown pathophysiological hypotheses. In particular, they have studied if and when hypoperfusion determines a renal injury in a patient submitted to cardiac surgery. Using these methods, a description of hypoperfusion was generated and tested sufficiently deep and powerful to determine and distinguish between the hypoperfusive states that produce renal injury and the ones that never generate renal damage. >

The prevalence of human immunodeficiency virus (HIV) infection in older and elderly adults is significant worldwide. This population poses new challenges and opportunities in the management of HIV. In addition to the risks affecting HIV patients of all ages, including risk of opportunistic infection and medication resistance, age-related changes in physiology, higher comorbidity burdens, increased use of medications, and potential adverse drug reactions to HIV medications all factor into the care of older adults with HIV. The risk and progression of cardiovascular and renal comorbidities may be higher in the older adult HIV population and in patients taking specific HIV medications. Understanding these risks is essential when managing a new type of patient: the older adult with HIV.

Introduction 5-Amino salicylate (5-ASA) medications may rarely be associated with a significant decline in renal function and interstitial nephritis. The British Society of Gastroenterology guidelines 1 advise regular renal function monitoring for patients (pts) taking these drugs. This study assessed whether clinicians were following best practise guidelines. Methods Using longitudinal community and regional pathology databases for the East Kent population (720 k), our renal unit regularly screens a total population of 300,000 for evidence of renal disease. The data extracted is analysed using the SEIK (System for Early Identification of Kidney disease), an automated computerised system to identify pts requiring intervention for kidney disease. As part of this process, all patients taking 5-ASA medication were identified. The pathology database was studied to identify the pts on treatment who had had renal function tests and could differentiate from results initiated in primary and secondary care. Data analysis can be performed over many years of treatment. Results 800 adult pts (M : 341, F 459) identified taking 5-ASA therapy (median duration 1.5 years (range 1–24 yr); mean (+/- SD) age 52.7 +/- 16.2 yr (range 18.2–94.4). The mean estimated Glomerular Filtration Rate (eGFR) on commencing 5-ASA therapy was 82 ml/min (range 28 - > 90). Pts with an eGFR 293 (48%) pts had no renal function cheques whilst on treatment. 79 (12%) pts had renal function tests less than once every 4 years and 36 pts once every 2 – 4 yrs. 204 pts had renal function measurements in 50% or more of years of treatment, of whom 116 were checked every year. 72 pts with a baseline eGFR 2ml/min/yr. Conclusion The majority of pts receiving 5-ASA compounds do not have regular renal function monitoring. Some are started on treatment with abnormal results at baseline and some with identified kidney disease continued on their 5-ASA’s. Gastroenterologists are failing to follow best practise guidelines. Disclosure of Interest None Declared. Reference Mowat et al. Guidelines for the management of inflammatory bowel disease in adults. Gut 2011; 60 : 571 – 607.

THE GLOBAL SUPPLY of medical isotopes has been disrupted for the second time in less than a year—this time by the temporary shutdown of a nuclear reactor in Canada. The reactor, in Chalk River, Ontario, will be out of service for more than three months while its operator, Atomic Energy of Canada, investigates a heavy-water leak. The facility is a major source of molybdenum-99, which is used to generate technetium-99m for diagnostic nuclear medical procedures such as cardiac blood-flow imaging, bone scanning for secondary tumors, and renal function monitoring. The reactor produces 30 to 40% of the world’s medical isotopes and approximately 50% of those used in North America, estimates MDS Nordion, a pharmaceutical isotope supplier. The shutdown has left MDS and other providers of medical isotopes scrambling for additional sources. Molybdenum-99 cannot be stockpiled because of its 67-hour half-life, and it is produced by only five nuclear reactors from highly enriched uranium-235, also used ...

A shortage of medical isotopes has developed in Europe, according to the European Association of Nuclear Medicine. The association says that nuclear medical clinics can no longer carry out a large part of their diagnostic and therapeutic activities and that many patients face danger to their health. The isotopes—primarily molybdenum-99, from which technetium-99m is generated—are used in more than 80% of routine nuclear-imaging tests for procedures such as cardiac blood-flow imaging, bone scanning for secondary tumors, and renal function monitoring. The shortage stems from temporary shutdowns of the major nuclear reactors that make the isotopes. They are down for several reasons, including routine maintenance, repairs following a lightning strike, and the correction of operating errors, pointed out Andrew Hilson, a nuclear medicine specialist at the Royal Free Hospital, in London, in a recent BBC Radio interview. The situation became serious after the late-August idling of a reactor in Petten, the Netherla...