02 Renal

SCHLEGEL RENAL PROTOCOL
Richard Prima, R.T. (ASRT)

Tulane University Hospital and Clinics
Department of Urology
and
General Electric Medical Systems
August 18th, 1989

CONTENTS
1. PATIENT PREPARATION AND SETUP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 - 1

Pharmaceutical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-1
Collimator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-1
Patient Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-1
Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-1
Dosage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-1
Injection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-2
2. HOW TO USE THE SYRINGE HOLDER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 - 1

3. ACQUISITION PROTOCOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 - 1
Hippuran Acquisition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-1
Hippuran 15 Minute Static Acquisition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-3
Hippuran 25 Minute Static Acquisition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-4
Hippuran Bladder Acquisition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-4
TC-99M-DTPA Acquisition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-5
Both Hippuran and Tc-99m-DTPA Acquisitions . . . . . . . . . . . . . . . . . . . . . . . 3-6
4. HOW TO DETERMINE URINE VOLUME AND COUNTS . . . . . . . . . . . . . . . . 4 - 1

5. PROCESSING PROTOCOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 - 1
Hippuran Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 - 2
Tc-99m-DTPA Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 - 4
Hippuran Bladder Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 - 7
6. PROCESSING OPTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 - 1
6.1Generate Hippuran Early/ Middle/ Late Phase Images . . . . . . . . . . . . . . . . 6-1
6.2Generate Hippuran One Minute Count Totals . . . . . . . . . . . . . . . . . . . . . . . . 6-2
6.3Hippuran 15 & 25 Minute Image Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-4
6.4Generate Tc-99m-DTPA One Minute Count Totals . . . . . . . . . . . . . . . . . . 6-6
7. REVIEW MODES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 - 1
Hippuran Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-1
Hippuran Summed Images . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-2
Hippuran One Minute Count Totals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-2
Hippuran 15 & 25 Minute Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-3
Tc-99m-DTPA Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-3
Tc-99m-DTPA One Minute Count Totals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-4
Hippuran Bladder Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-4
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8. THEORY OF OPERATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 - 1
Global and Differential ERPF's . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 - 1
I131 Hippuran Individual Kidney Contributions . . . . . . . . . . . . . . . . . . . . . . . . . 8 - 2
Expected Normal ERPF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 - 2
I131 Hippuran Returns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 - 3
Filtration Fractions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 - 3
Total and Differential GFR's . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 - 3
Normal Total GFR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 - 4
Tc-99m-DTPA Individual Kidney Contributions . . . . . . . . . . . . . . . . . . . . . . . . 8 - 4
Bladder Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 - 4
9. REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 - 1
APPENDIX A - DATASETS SAVED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A - 1
APPENDIX B - DESCRIPTION OF SCRATCHPAD . . . . . . . . . . . . . . . . . . . . . . . B - 1
APPENDIX C - HEIGHT AND WEIGHT CONVERSION TABLES . . . . . . . . . . C - 1
APPENDIX D - PATIENT INFORMATION FORM . . . . . . . . . . . . . . . . . . . . . . . . D - 1
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1. PATIENT PREPARATION AND SETUP
Pharmaceutical
Use I131 hippuran for the hippuran acquisitions.

Use Tc-99m-DTPA for the technetium acquisitions.
The Tc-99m-DTPA package insert suggests that it be used within one hour for GFR determinations.
Check the Tc-99m-DTPA for purity also. The presence of TcO4 in Tc-99m-DTPA decreases GFR values
exponentially by as much as 26%. (9)
Collimator
A high energy collimator should be used with I131 hippuran. A medium energy collimator causes the
activity to `blur out' from the kidneys, and makes it very difficult to determine where the edge of the kidney
actually is.
The high energy collimator can also be used for the Tc-99m-DTPA acquisitions.
Patient Preparation
Prior to the start of the study, the patient should empty their bladder.
It is important that the patient be in a state of normal hydration for bladder imaging.
To ensure adequate hydration, children are routinely given one and a half 6 ounce cups of water before the
study, and adults are given two and a half 6 ounce cups of water.
Patient Positioning
Patients are usually in a supine position with the detector placed under the imaging table. For transplant
patients, however, the detector is placed over the patient's abdomen.
For bladder imaging, patients can also be in a supine position with the bladder centered in the imaging field
of the detector.
Dosage
Dr. Schlegel recommends the following doses based on age:

I131 hippuran:
50 microcuries for children less than 6 months.
100 microcuries for children 6 - 24 months.
200 microcuries for children 2 - 12 years.
300 microcuries for patients older than 12 years.
The I131 hippuran dose should be diluted with normal saline to 2.5 ml.
Tc-99m-DTPA:
1 millicurie for patients older than 12 years.
The Tc-99m-DTPA dose should be diluted with normal saline to 2.5 ml.
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Injection
Use a 3 cubic centimetre syringe.
After the syringe is filled, but before it is diluted, put the syringe in a dose calibrator and record the activity.
Be sure to dilute the dose before the pre syringe static acquisition.
The injection should be delivered as a bolus. It should be flushed with the patient's blood.
If at all possible, do not inject through IV tubing. If IV tubing is used, do not use a large diameter or a long
length of tubing. The injection should still be delivered as a bolus and flushed with a saline solution. For
butterfly tubing, flush with 2 or 3 cubic centimetres of saline.
After the injection, put the empty syringe back in the dose calibrator to make sure the whole dose was
injected. If it was not, be sure to use the dose injected as measured by the dose calibrator for the information
requested on the bladder form. This is the only place in the protocols that actually uses the dose in
calculations and it needs to be accurate.
Any infiltration of the dose would make the results inaccurate.
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2. HOW TO USE THE SYRINGE HOLDER
The syringe holder is used to support the syringe for a static image before injection.
When you are ready to image the syringe, place the syringe holder on the same table as the one that will be
used for the dynamic acquisition. Position the detector underneath this table.
For a transplant patient, place the syringe holder on the camera face.
Syringe flange must
rest on surface
3 cc Syringe
18 cm
Position the syringe vertically in the syringe holder as illustrated. With the syringe flange resting on the
surface, the flange will be 23 centimetres from the bottom of the syringe holder. The bottom of the syringe
will be 18 centimetres from the bottom of the syringe holder.
The attenuator plate should not be used with the syringe holder for the Schlegel method.
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RETURN
To invoke the Schlegel Renal Protocol, type `SCHLEGEL' and press .
The following menu will then be displayed:
SCHLEGEL RENAL PROTOCOL

[ 1 ] Acquisition
[ 2 ] Processing
[ 3 ] Review
[ 0 ] Exit
Please enter selection followed by <SEND FORM>
When either 1, 2 or 3 are selected, a patient selection protocol will be invoked to select or create a patient. If
option 1 is selected, a new patient can be created or an existing patient can be selected. With options 2 and
3 only patient selection is allowed.
Once patient selection/creation has been completed, the study SCHLEGEL RENAL will be created or if
present, selected.
Selecting option 1 calls the acquisition protocol, SCHLACQ. Selecting option 2 calls the processing
protocol, SCHLPROCESS. Selecting option 3 calls the review protocol, SCHLREVIEW.
3. ACQUISITION PROTOCOL
Upon entering the acquisition protocol, the system type is determined. If the system is a Maxxus, the
following screen is displayed:
Maxxus Detector Selection Menu
[ 1 ] Detector 1
[ 2 ] Detector 2
Please select detector for acquisition
This acquisition protocol is designed to be flexible, since it is not always possible to know at the start of a
study which acquisitions need to be performed.
You can keep on using this acquisition protocol until all the acquisitions have been completed. They will all
be stored under the same study `SCHLEGEL RENAL'.
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The following menu will be displayed:
Schlegel acquisitions
1. Hippuran acquisition
2. Hippuran 15 minute static acquisition
3. Hippuran 25 minute static acquisition
4. Hippuran bladder acquisition
5. Tc–99m–DTPA acquisition
6. Both hippuran and Tc–99m–DTPA acquisitions
Enter choice of acquisition & press SEND FORM key
?:
The Schlegel acquisition protocol allows you to acquire I131 hippuran flow data, I131 15 and/or 25 minute
static images, I131 hippuran bladder data, and Tc-99m-DTPA flow data.
I131 hippuran analysis will determine individual kidney contributions and global and differential effective
renal plasma flows (ERPF's).
Tc-99m-DTPA analysis by itself will determine individual kidney contributions.
I131 hippuran analysis followed by Tc-99m-DTPA analysis will determine individual kidney contributions,
global and differential ERPF's, glomerular filtration rates (GFR's), and filtration fractions (FF's). For this case,
the Tc-99m-DTPA must be acquired before the hippuran data.
Hippuran bladder analysis will determine voided and residual volumes and returns.
Hippuran 15 and 25 minute analysis will determine individual kidney background subtracted counts and
percent contributions.
Hippuran acquisition
SEND FORM
To acquire the I131 hippuran data, enter a `1' when the acquisition menu is displayed, and press
to continue.
If the I131 hippuran energy correction file I131CORR does not exist, the form for ASES will be displayed and
SEND FORM
you will need to select the appropriate energy correction file. Press to continue.
The acquisition protocol will then set up the following two acquisitions:
1. Static dataset - PRE SYRI
This is a 64 x 64, word mode static image of the syringe before injection. The acquisition will
terminate by time, which is set for 60 seconds. Since the counts from this image are extrapolated to
one minute, the acquisition time can be modified if necessary. The resolution can be changed to 128
x 128.
2. Dynamic dataset - REN FLWI
This is a 64 x 64, word mode dynamic acquisition, 6 seconds per frame for 100 frames (10 minutes).
The frame rate can be changed as long as it can be evenly divided into 60 seconds. However, it is
recommended to keep the total number of frames below 150 to avoid display memory problems.
The resolution can be changed to 128 x 128.
Note: You can acquire this data in byte mode if you desire, but you will need to convert it to word
mode and rename it to REN FLWI before it can be processed.
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The following form will then be displayed:
ORSP––––––––––––––––––––––––––––––––––––––––SCHLEGEL RENAL PROTOCOL

Height (cm) :
Weight (kg) :
Kidney depth (1=auto 2=manual) :
Age :
Systolic blood pressure :
Diastolic blood pressure :
Dose (mci) :
Hydrated? (1=yes 2=no) :
Type in the patient's height in centimeters, weight in kilograms, and method of determining kidney depth
(automatic or manual). This information is required by the processing protocol.
If the manual method of determining kidney depth is chosen, kidney depths should be determined by
ultrasound or CT. The kidney depth values are the mid-plane values.
If the automatic method of determining kidney depth is chosen, kidney depths will be determined by the
formulas of Tonnesen, et al.
The patient's age in years, blood pressure, injected dose in millicuries, and state of hydration are optional. If
these values are entered on the form, they will be displayed on the final review screens with the calculated
results.
SEND FORM
Press to enter the patient information. These values will be transferred to the scratchpad.
If this information has already been entered for a previous acquisition, the form will not be displayed.
The acquisitions will then be queued up, and the system will be in camera mode.
The first acquisition, the static image of the syringe before injection, will be ready to acquire.
Place the syringe containing the I131 hippuran dose to be injected vertically in the syringe holder as
illustrated in section 2.
Place the syringe holder on the same table as the one that will be used for the dynamic acquisition. Position
the detector under the table. For a transplant patient, place the syringe holder on the camera face.
ENERGY
When the syringe holder and detector are properly positioned, press to check the spectrum for I131
CAMERA
hippuran. When you are satisfied that the spectrum is in the correct setting, press to return to
camera mode.
ACQ START
Press to start the static acquisition.
When the static acquisition is complete, the dynamic acquisition will be ready to acquire.
Position the patient supine with the detector under the table. The patient's kidneys should be centered in
the field of view. For a transplant patient, position the patient supine with the detector above the patient.
Have the transplant kidney centered in the field of view.
ACQ START
When the patient, detector, and table are properly positioned, inject the patient and press to
start the dynamic acquisition.
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Make sure that the patient does not move during the acquisition.
When the acquisitions are complete, the patient information stored in the scratchpad will be saved as a
dataset. The name of the dataset is SCHL DATA.
Hippuran 15 minute static acquisition

To acquire the I131 hippuran 15 minute static image, enter a `2' when the acquisition menu is displayed, and
SEND FORM
press to continue.
If the I131 hippuran energy file I131CORR does not exist, the form for ASES will be displayed and you will
SEND FORM
need to select the appropriate energy correction file. Press to continue.
The acquisition protocol will then set up the following acquisition:
1. Static dataset - H15MIN
This is a 64 x 64 word mode static image of the kidneys taken 15 minutes post injection. The
acquisition will terminate by time, which is set for 60 seconds. Since the counts from this image are
extrapolated to one minute, the acquisition time can be modified if necessary. The resolution can be
changed to 128 x 128.
If patient information was not previously entered, the form for ORSP will be displayed as described in the
SEND FORM
hippuran acquisition section. Press to continue.
The acquisition will then be queued up, and the system will be in camera mode.
This image should be acquired 15 minutes post injection.
ACQ START
When the patient, detector and table are properly positioned, press to start the acquisition.
When the acquisition is complete, the patient information stored in the scratchpad will be saved as a
Hippuran 25 Minute Static Acquisition

To acquire the I131 hippuran 25 minute static image, enter a `3' when the acquisition menu is displayed, and
SEND FORM
press to continue.
If the I131 hippuran energy file I131CORR does not exist, the form for ASES will be displayed and you will
SEND FORM
The acquisition protocol will then set up the following acquisition:
1. Static dataset - H25MIN
This is a 64 x 64 word mode static image of the kidneys taken 25 minutes post injection. The
acquisition will terminate by time, which is set for 60 seconds. Since the counts from this image are
If patient information was not previously entered, the form for ORSP will be displayed as described in the
SEND FORM
hippuran acquisition section. Press to continue.
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The acquisition will then be queued up, and the system will be in camera mode.
This image should be acquired 25 minutes post injection.
ACQ START
When the patient, detector and table are properly positioned, press to start the acquisition.
When the acquisition is complete, the patient information stored in the scratchpad will be saved as a
Hippuran Bladder Acquisition

For accurate results, the bladder images should be acquired 30 minutes post I131 hippuran injection.
These acquisitions should be performed with I131 hippuran. Any counts present from another
radiopharmaceutical, including Tc-99m-DTPA, may cause erroneous results.
When you are ready to acquire the I131 hippuran bladder data, enter a `4' when the acquisition menu is
SEND FORM
displayed, and press to continue.
If the I131 hippuran energy correction file I131CORR does not exist, the form for ASES will be displayed and
SEND FORM
1. Static dataset - PREVOID
This is a 64 x 64, word mode, 60 second static image of the bladder before voiding. For an accurate
estimate of bladder function, this image should be acquired 30 minutes post injection. The
resolution can be changed to 128 x 128.
2. Static dataset - POSTVOID
This is a 64 x 64, word mode, 60 second static image of the bladder after voiding. The resolution
can be changed to 128 x 128.
If the patient information was not previously entered, the ORSP form will be displayed. Enter the necessary
SEND FORM
patient information as described in the hippuran section. Press to continue.
The first acquisition, the static image of the bladder before voiding, will be ready to acquire. For an accurate
estimate of bladder function, this image should be acquired 30 minutes post injection. Position the patient in
a supine position and centre the patient's bladder within the field of view. The detector should be above the
patient.
ENERGY
When the patient and detector are properly positioned, press to check the spectrum. When you are
CAMERA
satisfied that the spectrum is in the correct setting for I131 hippuran, press to return to camera
mode.
ACQ START
Press to start the prevoid acquisition.
The patient should void as soon as the prevoid acquisition is complete. Voiding should take place 30
minutes post injection. Save the collected urine for volume and count measurements.
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After the patient has voided, position the patient as for the prevoid acquisition. The last acquisition, the
postvoid bladder static, will be ready to acquire.
ACQ START
When the patient is properly positioned, press to start the postvoid acquisition.
When the acquisitions are complete, the patient information stored in the scratchpad will be saved as a
Before processing the bladder data, you will need to measure the volume of urine voided, and determine
dose calibrator readings of the urine sample as described in the next section of the manual.
Tc-99m-DTPA acquisition
To acquire the Tc-99m-DTPA data, enter a `5' when the acquisition menu is displayed, and press
SEND FORM
to continue.
If the technetium energy correction file TcCorr does not exist, the form for ASES will be displayed and you will
SEND FORM
1. Static dataset - PRE SYRT
This is a 64 x 64, word mode static image of the syringe before injection. The acquisition will
terminate by time, which is set for 3 seconds. Since the counts from this image are
2. Dynamic dataset - REN FLWT
The frame rate can be changed as long as it can be evenly divided into 60 seconds. However, it is
recommended to keep the total number of frames below 150 to avoid display memory problems.
The resolution can be changed to 128 x 128.
Note: You can acquire this data in byte mode if you desire, but you will need to correct it to word
mode and rename it to REN FLWT before it can be processed.
If patient information was not previously entered, the ORSP form will be displayed. Enter the necessary
SEND FORM
patient information as described under the hippuran acquisitions section. Press to continue.
The first acquisition, the static image of the syringe before injection, will be ready to acquire.
Place the syringe containing the Tc-99m-DTPA dose to be injected vertically in the syringe holder as
illustrated in section 2.
Place the syringe holder on the same table as the one that will be used for the dynamic acquisition. Position
ENERGY
When the syringe holder and detector are properly positioned, press to check the spectrum for
Tc-99m-DTPA. When you are satisfied that the spectrum is in the correct setting, press CAMERA to return
to camera mode.
ACQ START
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When the static acquisition is complete, the system will set up the dynamic acquisition.
ACQ START
The patient information stored in the scratchpad will be saved as a dataset. The name of the scratchpad
dataset is SCHL DATA.
Both hippuran and Tc-99m-DTPA acquisitions

To acquire both the I131 hippuran and Tc-99m-DTPA data, enter a `6' when the acquisition menu is
SEND FORM
displayed, and press to continue.
When both I131 hippuran and technetium data are being acquired, the technetium data will be acquired
before the I131 hippuran data.
If the technetium energy correction file TcCorr does not exist, the form for ASES will be displayed and you will
SEND FORM
The acquisition protocol will then set up the following two acquisitions as described in the Tc-99m-DTPA
acquisition section.
1
If the I131 hippuran energy correction file I13 CORR does not exist, the form for ASES will be displayed and
SEND FORM
The acquisition protocol will then set up two more acquisitions as described in the hippuran acquisition
section.
3. Static dataset - PRE SYRI
ORSP–––––––––––––––––––––––––––––––––––––––––SCHLEGEL RENAL PROTOCOL

Height (cm) :
Weight (kg) :
Age :
Dose (mci) :
Type in the patient's height in centimeters, weight in kilograms, and method of determining kidney depth
(automatic or manual). This information is required by the processing protocol.
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If the manual method of determining kidney depth is chosen, kidney depths should be determined by
ultrasound or CT. The kidney depth values are the mid-plane values.
If the automatic method of determining kidney depth is chosen, kidney depths will be determined by the
formulas of Tonnesen, et al.
The patient's age in years, blood pressure, dose injected in millicuries (for this acquisition the dose refers to
the hippuran dose), and state of hydration are optional. If these values are entered on the form, they will be
displayed on the final review screens with the calculated results.
SEND FORM
Press to enter the patient information. These values will be transferred to the scratchpad.
The acquisitions will be queued up in the following order:
I131 hippuran pre syringe static
Tc-99m-DTPA pre syringe static
Tc-99m-DTPA dynamic
I131 hippuran dynamic
The system will be in camera mode.
The first acquisition, the static image of the I131 hippuran syringe before injection, will be all set up.
Place the syringe containing the I131 hippuran dose to be injected vertically in the syringe holder as
illustrated in Section 2.
Place the syringe holder on the same table as the one that will be used for the dynamic acquisitions. Position
Press ENERGY
to check the spectrum for I13 1 hippuran. When you are satisfied that the spectrum is in the
CAMERA
correct setting, press to return to camera mode.
ACQ START
When the static acquisition is complete, the second acquisition, the static image of the Tc-99m-DTPA
syringe before injection will be set up.
Place the syringe containing the Tc-99m-DTPA dose to be injected vertically in the syringe holder. The
syringe holder should already be properly positioned.
Press ENERGY
to check the Tc-99m-DTPA spectrum. When you are satisfied that the spectrum is in the
CAMERA
correct setting, press to return to camera mode.
ACQ START
When the Tc-99m-DTPA pre syringe static is complete, the Tc-99m-DTPA dynamic acquisition will be
ready to acquire.
When the patient, detector, and table are properly positioned, inject the patient with the Tc-99m-DTPA
ACQ START
dose and press to start the dynamic acquisition.
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When the Tc-99m-DTPA dynamic acquisition is complete, the I131 dynamic acquisition will be ready to
acquire.
Inject the patient with the I131 hippuran dose and press ACQ START
to start the dynamic acquisition.
The patient information stored in the scratchpad will be saved as a dataset. The name of the scratchpad
dataset is SCHL DATA.
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4. HOW TO DETERMINE URINE VOLUME AND COUNTS
You will need to determine the volume of urine voided and the counts for a urine sample before processing
the bladder data.
The patient should void at the proper time. Voiding should take place 30 - 35 minutes post injection, after
the prevoid acquisition of the bladder is complete.
Measure the volume of urine voided. Then withdraw 2.5 ml of urine for the dose calibrator readings.
Set the background of the dose calibrator to zero. Take three readings of the 2.5 ml sample of undiluted
urine. Record each of the readings. Take a background reading and record it.
The volume of voided urine, three dose calibrator readings, and background reading will be used in the
bladder processing portion of the protocol.
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5. PROCESSING PROTOCOL
The Gates processing protocol can be invoked from the SCHLEGEL protocol via menu option
`2'.
You can also access the processing protocol by selecting the patient and study to be
processed and typing `SCHLPROCESS'.
Schlegel Renal Processing
1 Hippuran analysis (ERPF)

2 Generate hippuran early/middle/late phase images
3 Generate hippuran one minute count totals
4 Hippuran 15 & 25 minute image analysis
5 Tc–99m–DTPA analysis (GFR and FF if hippuran already processed
6 Generate Tc–99m–DTPA one minute count totals
7 Hippuran bladder analysis
8 Complete hippuran and Tc–99m–DTPA processing
9 Review processed data
Enter option & press SEND FORM key or ESCAPE to exit

? :
Option 1 will determine the individual kidney contributions and the global and differential
ERPF's.
Option 2 will reframe the I131 hippuran dynamic data into early, middle and late phase
summed images.
Option 3 will normalize the I131 hippuran background subtracted kidney curves to counts
versus minutes and generate one minute count totals for the 10 minutes of the
dynamic acquisition.
Option 4 will determine individual kidney background subtracted counts and percent
contribution for the 15 and 25 minute static images.
Option 5 will determine the individual kidney contributions and, if the I131 hippuran data was
already processed, the global and differential GFR's, and left and right filtration
fractions.
Option 6 will normalize the Tc-99m-DTPA background subtracted kidney curves to counts
versus minutes and generate one minute count totals for the 3 minutes of the
dynamic acquisition.
Option 7 will analyze the I131 hippuran bladder data.
Option 8 is a combination of options 1 - 3 and 5 - 6. It will perform sections that require user
interaction first.
Option 9 is a review of the processed data.
ESCAPE
To exit the protocol, press .
Sch5-1
This section deals with options 1, 5, and 7. These are the options that process the I131
hippuran, Tc-99m-DTPA and bladder data.
Options 2, 3, 4, and 6, which are extra features of the program, will be discussed in Section 5 of
the manual, `Processing Options'.
Option 8 is simply a combination of options 1 - 3 and 5 - 6.
Hippuran Analysis
To process the I131 hippuran data, enter a `1' when the processing menu is displayed, and
SEND FORM
press to continue.
If the dataset REN FLWI is byte mode, you will be informed of this and exit the protocol. Convert
this dataset to word mode and rename it back to REN FLWI and then it can be processed.
The protocol will first check to make sure the scratchpad exists and contains the patient
information. If the scratchpad doesn't exist, it will be created and you will be prompted to enter
the patient information as described in the acquisition protocol section. If the scratchpad exists
but the patient information is missing, you will be prompted to enter the patient information.
The protocol will then perform some housekeeping and delete previously processed datasets
if they exist.
The dynamic dataset REN FLWI will be displayed in quadrant 4, and a 1-5 minute summed
image will be created in quadrant 1.
You will then be prompted to outline the kidney and background ROI's on the composite image
in quadrant 1. The ROI's will be duplicated on the dynamic dataset in quadrant 4.
You will see the following message:
Outline right kidney on 1–5 minute image.
Since imaging was done posteriorly, if this is a two kidney patient, the right kidney will be on the
right side of the image.
Use POSN , TRACE , JOIN and ERASE to outline the right kidney on the 1-5 minute summed
END
image in quadrant 1. Press twice to continue.
If there is no right kidney, or if you are processing a transplant patient:
END
Press once before pressing POSN , TRACE , JOIN or ERASE when the RIRR form
for outlining the right kidney is displayed.
END
Pressing in this way will notify the protocol that you only want to process the left
kidney. You will not have to outline the right kidney. Everything in the processing and
review protocols from this point on will be in terms of the left kidney.
The next message will be displayed:
Outline left kidney on 1–5 minute image.
Sch5-2
Use POSN , TRACE , JOIN and ERASE to outline the left kidney on the 1-5 minute summed
END
If there is no left kidney:
END
for outlining the left kidney is displayed.
END
Pressing in this way will notify the protocol that you only want to process the right
kidney. You will not have to outline the left kidney. Everything in the processing and
review protocols from this point on will be in terms of the right kidney.
Outline triangular background below & between kidneys
Use POSN , TRACE , JOIN and ERASE to draw a triangular background ROI on the 1-5 minute
summed image in quadrant 1. Place the background ROI below and between the two kidneys
as illustrated. Make the background ROI large enough to adequately sample the background.
END
Press twice to continue.
Kidney and background ROI's
The kidney and background curves will be generated and displayed in quadrant 3.
If the manual method of determining kidney depth was chosen, you will see the following
message:
Enter right kidney depth in cm & press SEND FORM key
Enter the mid-plane right kidney depth in centimetres as determined by ultrasound or
SEND FORM
CT. Press to continue.
Likewise, you will be prompted to enter the left mid-plane kidney depth in
SEND FORM
centimetres. Press to continue.
If only one kidney is being processed, and the manual method of determining kidney
depth was chosen, you will only be prompted to enter the kidney depth for that kidney.
The background subtracted kidney curves will be generated and displayed in quadrant 2.
Sch5-3
The protocol will then calculate results. The bottom half of the display will be cleared and the
patient information and ERPF Report will be displayed.
The review menu will be displayed on the alphanumeric screen.
These results are available for review any time after the data has been processed. Type in
`SCHLPROCESS' to initiate the Schlegel renal protocols and then select Òption 9 - Review
processed data'.
You can also access review modes by typing in `SCHLREVIEW' to initiate the Schlegel review
protocol.
Review modes are further described in section 6.
Tc-99m-DTPA Analysis
To process the Tc-99m-DTPA data, enter a `5' when the processing menu is displayed, and
SEND FORM
press to continue.
If the dataset REN FLWT is byte mode, you will be informed of this and exit the protocol.
Convert this dataset to word mode and rename it back to REN FLWT and then it can be
processed.
The protocol will first check to make sure the scratchpad exists and contains the patient
information. If the scratchpad does not exist, it will be created and you will be prompted to
enter the patient information as described in the acquisition protocol section. If the scratchpad
exists but the patient information is missing, you will be prompted to enter the patient
information.
The protocol will also check to see if the I131 hippuran data has been processed. If it has, the
following message will be displayed:
Enter Tc–99m–DTPA dose in mci & press SEND FORM key
SEND FORM
Type in the Tc-99m-DTPA dose in millicuries and press to continue.
if they exist.
The dynamic dataset REN FLWT will be displayed in quadrant 4, and a 1-3 minute summed
image will be created in quadrant 1.
You will then be prompted to outline the kidney and background ROI's. The method of
generating these ROI's will differ, depending on whether or not the I131 hippuran data was
already processed.
If the I131 hippuran data has not been processed:
The following message will be displayed:
Sch5-4
Since imaging was done posteriorly (if this is a two-kidney patient), the right kidney
will be on the right side of the image.
Use POSN , TRACE , JOIN and ERASE to outline the right kidney on the 1-5 minute
END
summed image in quadrant 1. Press twice to continue.
END
for outlining the right kidney is displayed.
END
Pressing in this way will notify the protocol that you only want to process the left
kidney. You will not have to outline the right kidney. Everything in the processing and
review protocols from this point on will be in terms of the left kidney.
Outline left kidney on 1–3 minute image.
Use POSN , TRACE , JOIN and ERASE to outline the left kidney on the 1-5 minute summed
END
END
for outlining the left kidney is displayed.
END
Pressing in this way will notify the protocol that you only want to process the right
kidney. You will not have to outline the left kidney. Everything in the processing and
Outline triangular background below & between kidneys.
Use POSN , TRACE , JOIN and ERASE to draw a triangular background ROI on the 1-5 minute
summed image in quadrant 1. Place the background ROI below and between the two kidneys
as illustrated. Make the background ROI large enough to adequately sample the background.
END
Press twice to continue.
Kidney and background ROI's
Sch5-5
If the I131 hippuran data has already been processed:
The I131 hippuran right kidney ROI will be displayed on the 1-3 minute summed
image in quadrant 1.
Manipulate ROI to fit right kidney.
POSN SIZE ROTATE MIRROR

Use , , , and to manipulate the I131 hippuran ROI to fit the
POSN SIZE END

right kidney. and are both very useful. Press to continue.
1 Manipulate ROI with RMAN (change ROI size/ position/ angle)

2 Modify ROI with RMOD (use ROI trace/ erase/ join)
3 Accept displayed ROI
Enter 1 or 2 to change ROI or 3 to continue & SEND FORM
? :
This menu will allow you to use RMAN or RMOD to further modify the right kidney ROI.
SEND FORM
Enter a `1' or a `2' and press to further modify the ROI, or enter a `3' and
SEND FORM
press to continue with the ROI as it is displayed.
In a similar manner, modify the left kidney and background ROI's when prompted. Let
the summed Tc-99m-DTPA image help you decide where to reposition the
background ROI.
If only one kidney was processed during the I131 hippuran portion of the protocol, you
will only be prompted to modify the ROI for that kidney.
When the kidney and background ROI's have been completed, they will be
superimposed on the dynamic dataset in quadrant 4.
If the manual method of determining kidney depth was chosen, and the I131 hippuran data
was not already processed, you will see the following message:
Enter the mid-plane right kidney depth in centimetres as determined by ultrasound or
SEND FORM
CT. Press to continue.
Likewise, you will be prompted to enter the left mid-plane kidney depth in
SEND FORM
centimetres. Press to continue.
If only one kidney is being processed, and the manual method of determining kidney
depth was chosen, you will only be prompted to enter the kidney depth for that kidney.
If the manual method of determining kidney depth was chosen, and the I131 hippuran data
was already processed, the protocol will automatically use the kidney depths entered during
I131 hippuran processing.
Sch5-6
The protocol will then calculate results. The bottom half of the display will be cleared and the
patient information and GFR Report will be displayed.
processed data'.
protocol.
Hippuran Bladder Analysis

For bladder analysis to be accurate the patient should not be injected with any other nuclide.
I131 hippuran should be the only isotope present in the patient. A Tc-99m-DTPA study
should not be performed prior to the I131 hippuran study.
To process the I131 hippuran bladder data, enter a `7' when the processing menu is displayed,
SEND FORM
and press to continue.
The protocol will first check to make sure the scratchpad exists. If the scratchpad doesn't exist,
it will be created.
ORBP––––––––––––––––––––––––––––––––––––––SCHLEGEL BLADDER PROTOCOL

Volume of urine voided (ml) :
First reading of urine sample :
Second reading of urine sample :
Third reading of urine sample :
Background reading :
Injected dose (same units as urine sample readings) :
Type in the volume of urine voided in millilitres, the first, second, and third dose calibrator
readings of the undiluted urine sample, the background dose calibrator reading, and the
amount of I131 hippuran injected. The units for the dose calibrator readings and the injected
dose should be the same. However, there is no need to actually type in the units.
The amount of I131 hippuran injected should be the amount determined by the dose
calibration as described in Section 1 of this manual.
SEND FORM
Press to enter the patient information.
If the data is being reprocessed, you will not have to re-enter the above information.
if they exist.
The prevoid bladder dataset will be displayed in quadrant 1.
Sch5-7
You will then be prompted to outline the prevoid bladder and background ROI on the image in
quadrant 1.
Outline bladder region on prevoid image.
Use POSN , TRACE , JOIN and ERASE to outline the bladder on the prevoid image in quadrant
END
1. Press twice to continue.
Outline prevoid background ROI above bladder avoiding ureters.
Use POSN , TRACE , JOIN and ERASE to outline a background region above the bladder on
END
the prevoid image in quadrant 1. Press twice to continue.
In a similar manner, outline the bladder and a background region on the postvoid image in
quadrant 2 when prompted.
The protocol will then check to see if the Tc-99m-DTPA dataset REN FLWT exists. If it does,
crosstalk from the Tc-99m-DTPA would make the results inaccurate. If this dataset is
present, a short form of bladder calculations will be done consisting of the pre and post void
background subtracted counts and percent counts remaining in the bladder after voiding.
After calculations, the patient information if present, and the bladder report will be displayed on
the bottom half of the display.
processed data'.
protocol.
Sch5-8
6. PROCESSING OPTIONS
6.1 Generate Hippuran Early/ Middle/ Late Phase Images
The I131 hippuran analysis will reframe the first half of the dynamic acquisition into a 1-5
minute summed image so that the user can outline the kidneys and a background region for
quantitation.
This option allows you to generate early (1-4 minutes), middle (4-7 minutes), and late (7-10
minutes) phase summed images from the dynamic acquisition.
Select the appropriate patient and Schlegel Renal study.
To start the processing protocol, type in the protocol name:
SCHLPROCESS
RETURN
and press .

5 Tc–99m–DTPA analysis (GFR and FF if hippuran already processed)

? :
SEND FORM
Enter a `2' and press to continue.
Housekeeping will be performed at the start of the protocol. Previously processed datasets
will be deleted if they exist.
The dynamic dataset REN FLWI will be displayed in quadrant 1. The 1-4 minute summed
image will be created in quadrant 2, the 4-7 minute summed image in quadrant 3, and the
7-10 minute summed image in quadrant 4. All of the summed images will be windowed
appropriately.
This display is available for review any time after processing. Type in `SCHLPROCESS' to
initiate the Schlegel renal protocols and then select Òption 9 - Review processed data'.
protocol.
Sch6-1
6.2 Generate Hippuran One Minute Count Totals
The I131 hippuran analysis will generate background subtracted individual kidney curves.
These curves will be expressed as counts per second versus seconds. The 1-2 minute count
totals derived from these curves are used by the protocol to estimate the total ERPF and will be
displayed in the I131 hippuran analysis review.
This option will allow the user to normalize the background subtracted kidney curves to counts
versus minutes, and to generate left and right one minute count totals for the 10 minutes of the
dynamic acquisition. Times to peak for each curve will also be determined.
The I131 hippuran analysis portion of the processing protocol needs to be done before this
option can be run.
SCHLPROCESS
RETURN
and press the key.


? :
SEND FORM
The protocol will first check to make sure that the I131 hippuran analysis has already been
done. If it has not, you will see the message:
Hippuran data has not been completely processed
You will still be in the processing menu where you can make another choice.
If the I131 hippuran analysis has been completed, the protocol will perform some
housekeeping and delete previously processed datasets if they exist.
The right kidney background subtracted curve will be displayed in quadrant 1. One minute
count totals for the first 10 minutes will be determined from the background subtracted curve.
Sch6-2
A check will be made on the acquisition time to see if the dynamic acquisition extended
beyond 10 minutes. If it did, further checks will be made to see if the acquisition extended to 15,
or 30 minutes. If the acquisition did extend to any of these times, one minute count totals will be
determined for them as well.
The curve will then be normalized, first to counts per minute versus minutes, and then to
counts versus minutes.
This sequence will be repeated for the left kidney background subtracted curve in quadrant 2.
The display will be cleared, and the normalized kidney curves will be displayed on the upper
half of the display. The time to peak in minutes for each curve will be displayed in the upper
right corner.
If this is a two kidney patient, a legend indicating which are the left and right kidney curves will
be displayed below the kidney curve axes.
The left and right one minute count totals for the 10 minutes of the dynamic acquisition will be
displayed on the lower half of the display. The total 1-2 minute counts will also be displayed.
If appropriate, left and right one minute count totals for the 14-15th, and 29-30th minutes will
be displayed.
protocol.
Sch6-3
6.3 Hippuran 15 & 25 Minute Image Analysis
The I131 hippuran analysis will generate individual kidney background subtracted counts and
percent contributions for the 1 - 2 minute interval.
This option will allow the user to generate individual kidney background subtracted counts
and percent contributions for the 15th and/or 25th minute post injection.
The I131 hippuran analysis portion of the processing protocol needs to be done before this
option can be run.
SCHLPROCESS
RETURN
and press the key.

? :
SEND FORM
The protocol will first check to make sure that the I131 hippuran analysis has already been
done. If it has not been done you will see the message:
Hippuran data has not been completely processed
The protocol will then check to make sure that the 15 and/or 25 minute static images exist.
If only the 15 minute image exists, it can be processed by itself. If the 25 minute image is
acquired later, it will be processed by itself, but the review screen will show the results of both
the 15 and 25 minute analyses. If only the 25 minute image exists, it can be processed by itself.
If neither the 15 or 25 minute images exist, the protocol will check to see if the dynamic dataset
REN FLWI extended past 15 or 25 minutes. If it did, it will generate a 15 and/or 25 minute image
from the dynamic data.
Sch6-4
if they exist.
The 15 minute image will be displayed in quadrant 1. The right image I131 hippuran ROI will be
superimposed on this image. The form for RMAN (manipulate ROI) will then be displayed. You
END
can accept this ROI as it is by pressing , or manipulate it using the keys listed on the
POSN
alphanumeric screen. will be very helpful. When the ROI has been manipulated, press
END
to continue.
1 Manipulate ROI with RMAN (change ROI size/ position/ angle

2 Modify ROI with RMOD (use ROI trace/ erase/ join)
3 Accept displayed ROI
Enter 1 or 2 to change ROI or 3 to continue & SEND FORM
? :
This menu allows you to further modify the ROI. You can use RMAN to size, position or rotate
SEND FORM
the ROI, or RMOD to erase and redraw a portion of the ROI. Enter a `3' and press
when you are satisfied with the ROI.
This process will be repeated for the left kidney and background ROI's.
If only one kidney was processed, only that kidney and the background ROI will be displayed
for modification.
Similarly, the 25 minute image will be displayed in quadrant 2, and you will be able to modify the
left, right and background ROI's for the 25 minute image.
The left, right, and total background subtracted counts; and the left and right percent
contributions will be calculated and displayed on the lower half of the display.
You can also access review modes by typing `SCHLREVIEW' to initiate the Schlegel review
protocol.
Sch6-5
6.4 Generate Tc-99m-DTPA One Minute Count TotalS
The Tc-99m-DTPA analysis will generate background subtracted individual kidney curves.
totals derived from these curves are used by the protocol to estimate the total GFR and will be
displayed in the Tc-99m-DTPA analysis review.
The Tc-99m-DTPA analysis portion of the processing protocol needs to be done before this
option can be run.
SCHLPROCESS
RETURN
and press .

? :
SEND FORM
The protocol will first check to make sure that the Tc-99m-DTPA analysis has already been
done. If it hasn't, you will see the message:
Tc-99m-DTPA data has not been completely processed
If the Tc-99m-DTPA analysis has been completed, the protocol will perform some
count totals for the first 3 minutes will be determined from the background subtracted curve.
Sch6-6
10, 15, or 30 minutes. If the acquisition did extend to any of these times, one minute count
totals will be determined for them as well.
right corner.
be displayed below the curve axes.
If appropriate, left and right one minute count totals for the 4-5th, 9-10th, 14-15th, and
29-30th minutes will be displayed.
protocol.
Sch6-7
Sch6-8
7. REVIEW MODES
All of the review modes are available any time after the data has been processed. There are 3
methods available to access the Schlegel review protocol.
1. The review protocol can be invoked from the SCHLEGEL protocol via menu option `3'.
2. You can also access the review modes by typing in `SCHLREVIEW' to initiate the Schlegel
review protocol.
3. Type in `SCHLPROCESS' to initiate the Gates renal protocols and then select Òption 9-
Review processed data'.
In either case, the following menu will be displayed:
Schlegel Renal Review

1 Hippuran analysis
2 Hippuran summed images
3 Hippuran one minute count totals
4 Hippuran 15 & 25 minute analysis
5 Tc–99m–DTPA analysis
6 Tc–99m–DTPA one minute count totals
4 Exit
Enter menu choice and press SEND FORM key
? :
Option 1 displays the 1-10 minute summed image with superimposed ROI's, background
subtracted curves, patient information, individual kidney contributions, and the
ERPF report.
Option 2 displays the reframed I131 hippuran early, middle, and late phase images.
Option 3 displays the I131 hippuran background subtracted kidney curves as counts versus
minutes, times to peak, and individual kidney one minute count totals.
Option 4 displays the 15 and/or 25 minute background subtracted counts and percent
contributions.
Option 5 displays the 1-3 minute summed image with superimposed ROI's, background
subtracted curves, patient information, individual kidney contributions, and the
GFR report.
Option 6 displays the Tc-99m-DTPA background subtracted kidney curves as counts
versus minutes, times to peak, and individual kidney one minute count totals.
Option 7 displays the I131 hippuran pre and postvoid bladder images with superimposed
ROI's, and the results of the bladder analysis.
Option 4 allows you to exit the protocol.
Sch7-1
Hippuran Analysis
This review mode displays the 1-5 minute summed image with superimposed ROI's,
background subtracted curves, patient information, individual kidney contributions, and the
ERPF report.
The 1 to 5 minute summed image with kidney and background ROI's superimposed will be
displayed in quadrant 1.
The background subtracted kidney curves will be displayed in quadrant 2. These curves will
be displayed as counts/sec versus seconds.
Patient information will be displayed in the lower half of the display. The patient's height in
centimetres and weight in kilograms will be displayed, and, if it was entered, so will the
patient's age in years, blood pressure, injected dose in millicuries and state of hydration. The
patient's body surface area in square metres, and left and right kidney depths in centimetres
will be displayed below this information. The one minute pre syringe counts (SYR CTS) will be
displayed in this same area.
The ERPF report will be displayed below the patient information.
This report includes the global and differential 1 to 2 minute counts, per cent contributions,
global and differential ERPF's, expected normal ERPF, 30 minute predicted return, and
expected normal return.
The expected normal ERPF (NORMAL ERPF) is a normal total ERPF of 600 times the patient's
body surface area divided by a standard body surface area of 1.73.
The 30 minute predicted return (30 MIN PRED RETURN) is the amount of I13 1 hippuran
predicted to return 30 minutes post injection.
The expected normal return (EXP NORMAL RETURN) is the expected return for a person with a
total ERPF of 600 and a standard body surface area of 1.73. This value will always be 68.
If only one kidney was processed, the 1-2 minute counts, per cent contribution, and ERPF
value for the missing kidney will appear as zeroes on the report, and only the one background
subtracted curve will be displayed.
Hippuran Summed Images

This option displays the early, middle, and late phase summed images generated from the
I131 hippuran dynamic dataset, REN FLWI.
The 1-4 minute summed image will be displayed in quadrant 1, the 4-7 minute summed
image in quadrant 2, and the 7-10 minute summed image in quadrant 3.
If the I131 hippuran data was processed, the 1-5 minute summed image used during
processing will be displayed in quadrant 4. The kidney and background ROI's will be
superimposed on the 1-5 minute summed image in quadrant 4.
Sch7-2
Hippuran One Minute Count Totals
This option displays the background subtracted kidney curves normalized to counts versus
The background subtracted, normalized kidney curves will be displayed on the upper half of
the display. These curves will be displayed as counts versus minutes. The time to peak in
minutes for each kidney curve (RTTP, LTTP) will be displayed above the curves.
The individual kidney one minute count totals will be displayed on the lower half of the display.
Left and right kidney one minute count totals will be displayed for the 10 minutes of the
dynamic acquisition. The total 1-2 minute counts will also be displayed.
If the dynamic acquisition extended to 15 or 30 minutes, the left and right one minute count
totals for the 14-15th minute, and 29-30th minute will be displayed.
If only one kidney was processed, only one background subtracted, normalized curve and
time to peak will be displayed, and the one minute count totals for the missing kidney will
appear as zeroes.
Hippuran 15 & 25 Minute Analysis

This review mode displays the 15 and/or 25 minute images, individual kidney background
subtracted counts, and percent contributions.
The 15 minute static image with superimposed kidney and background ROI's will be displayed
in quadrant 1.
The 25 minute static image with superimposed kidney and background ROI's will be displayed
in quadrant 2.
Counts and percent contributions will be displayed on the lower half of the display. The left and
right kidney background subtracted counts and percent contribution will be displayed for both
15 and 25 minutes.
If either the 15 minute or 25 minute data was not processed, these sections would be missing
on the review mode.
This review mode displays the 1-3 minute summed image with superimposed ROI's,
background subtracted curves, patient information, individual kidney contributions, and the
GFR report.
Sch7-3
will be displayed below this information. The one minute pre syringe counts (SYR CTS), will be
The GFR report will be displayed below the patient information.
This report includes the global and differential 1 to 2 minute counts, per cent contributions,
and, if the I131 hippuran data was already processed, global and differential GFR's, normal
total GFR, and left and right filtration fractions.
The normal total GFR (NORM GFR) is a normal total GFR of 120 times the patient's body
surface area divided by a standard body surface area of 1.73.
The filtration fraction (FILT FRACTION) is the ratio of the corrected uptake for Tc-99m-DTPA
to the corrected uptake for I131 hippuran times .47.
If only one kidney was processed, the 1-2 minute counts, per cent contribution, filtration
fraction and GFR value for the missing kidney will appear as zeroes on the report.
Tc-99m-DTPA One Minute Count Totals

Left and right kidney one minute count totals will be displayed for the 3 minutes of the dynamic
acquisition. The total 1-2 minute counts will also be displayed.
If the dynamic acquisition extended to 5, 10, 15, or 30 minutes, the left and right one minute
count totals for the 4-5th minute, 9-10th minute, 14-15th minute, and 29-30th minute will
be displayed.
appear as zeroes.

This review mode displays the I131 hippuran pre and postvoid bladder images with
superimposed ROI's, and the results of the bladder analysis.
The prevoid image with bladder and background ROI's superimposed will be displayed in
quadrant 1.
The postvoid image with bladder and background ROI's superimposed will be displayed in
quadrant 2.
Sch7-4
will be displayed below this information. The one minute pre syringe counts (SYR CTS) will be
The bladder report will be displayed below the patient information.
This report includes the actual volume of urine voided in millilitres, the calculated residual and
total urine volumes in millilitres, and the voided, residual, and total returns.
If the I131 hippuran analysis was also done, the 30 minute predicted return (PRED RETURN)
will be displayed below the total return.
If the Tc-99m-DTPA dataset REN FLWT was present at the time the bladder data was
processed, the short form of bladder processing was done. The Bladder Report would be
different in this case. The pre and post void images with superimposed ROI's would be
displayed on the top half of the display as before, followed by the patient information if present.
The bladder report would consist of pre and post void background subtracted counts and
percent counts remaining in the bladder after voiding.
Sch7-5
Sch7-6
8. THEORY OF OPERATION
The Schlegel renal protocol provides a nuclear camera based method of estimating effective
renal plasma flow (ERPF) using I131 hippuran. This method makes it possible to determine
total, as well as individual, kidney ERPF's by a radionuclide technique that requires neither
blood nor urine samples. Individual kidney percent contributions, expected normal ERPF, and
normal and predicted returns are also determined.
The Schlegel renal protocol can optionally evaluate urinary bladder function with I131
hippuran. Voided, residual, and total volumes and returns are determined.
When combined with Tc-99m-DTPA scintigraphy, the Schlegel renal protocol provides a
nuclear camera based method of estimating filtration fraction (FF) and glomerular filtration rate
(GFR). This combined method makes it possible to determine individual FF's, and total, as well
as individual, kidney GFR's for total renal function analysis. Individual kidney percent
contributions and normal total GFR are also determined. In the combined study, bladder
analysis is not performed.
If Tc-99m-DTPA scintigraphy is performed by itself, the Schlegel renal protocol will
determine only individual kidney percent contributions.
This method can be used with both adults and children, and on both two kidney and transplant
patients.
Global and Differential ERPF's
ERPF's are estimated from the renal uptake of I131 hippuran 1-2 minutes following injection,
before the urine has entered the renal collecting system.
To determine the 1-2 minute uptake, area normalized background counts are subtracted
from the radionuclide counts within each kidney. The background subtracted counts are then
corrected by multiplying with the square of the kidney depth where the kidney depth is the
mid-plane depth in centimetres.
Kidney depths can be measured by CT or ultrasound, or they can be estimated by the formulas
of Tonnesen et al (6).
Right kidney depth (cm) = 13.3 x (weight/height) + .7
Left kidney depth (cm) = 13.2 x (weight/height) + .7
where weight is in kilograms and height is in centimetres.
Finally, the renal uptake of I131 hippuran is calculated as a percentage of the administered
dose by dividing by the injected counts (preinjected counts - postinjection counts) and
multiplying by 100. Pre and post injection counts are determined from one minute pre and post
injection static acquisitions of the syringe.
2
1-2 minute background subtracted kidney counts x (kidney depth)
Uptake = x 100
preinjection counts - postinjection counts
The 30 minute return of I131 hippuran in the urine, when multiplied by the body surface area
(BSA), correlates closely with PAH clearances, another estimate of ERPF (1). An equation of
the form
Sch8-1
2
Y = AX + BX
has been found to relate the 30 minute return times BSA to the uptake of I131 hippuran, with Y
equal to return times BSA and X equal to the renal uptake of I131 hippuran as a percentage of
the administered dose.
The coefficients A and B were determined by regression analysis. With the coefficients in
place, the formula becomes:
Y = -.0002315X + .36987X
The 30 minute return times BSA can be converted to ERPF by multiplying by 5.029 (2).
ERPF = 5.029 x (30 minute predicted return x BSA)
The equation for the total ERPF in its final form is then:
Total ERPF = 5.029 x (.36987 x uptake - .0002315 x uptake )
Where uptake is the combined uptake of the two kidneys.
Left and right ERPF's are determined as follows:
left 1-2 minute background subtracted counts

left ERPF = total ERPF x
total 1-2 minute background subtracted counts
right 1-2 minute background subtracted counts

right ERPF = total ERPF x
total 1-2 minute background subtracted counts
I131 hippuran Individual Kidney Contributions

Individual kidney contributions are determined from the 1 to 2 minute background subtracted
kidney counts.
Left kidney contribution =
left kidney 1-2 min background subtracted counts
x 100
total 1-2 min background subtracted counts
Right kidney contribution =
right kidney 1-2 min background subtracted counts

x 100
Expected Normal ERPF

The expected normal ERPF is a normal total ERPF of 600 millilitres per minute adjusted to the
patient's body surface area.
Expected normal ERPF (ml/min) = 600 (ml/min) x BSA (sq m)/1.73 (sq m)
where the Boyd formula is used to calculate body surface area. (7)
Sch8-2
.3 .7285 - .0188 log weight
BSA (sq m) = .0003207 x (height) x (weight)
and height is in centimetres and weight is in grams.
1.73 square metres is a standard body surface area.
I131 Hippuran Returns
The 30 minute predicted return is the percentage of injected I131 hippuran one would expect
to collect in the urine at 30 minutes post injection. The 30 minute predicted return is related to
ERPF by the relationship:
ERPF = 5.029 x (30 minute predicted return x BSA)
as described above.
Solving for the return,
total ERPF (ml/min)
30 minute predicted return (%) =
BSA (sq m) x 5.029
The expected normal return is the percentage of injected I131 hippuran one would expect for
an individual with a normal total ERPF of 600 milliliters per minute and a standard body surface
area of 1.73 square metres. The expected return is always set to 68%.
Filtration Fractions
The filtration fraction (FF) is determined by dividing the corrected uptake for Tc-99m-DTPA
by the corrected uptake for I131 hippuran. Due to the characteristics of the scintillation
camera, it is necessary to multiply the ratio of the uptakes by .47 (3).
Right FF = right Tc-99m-DTPA uptake x .47

right I131 hippuran uptake
left Tc-99m-DTPA uptake x .47
Left FF = left I131 hippuran uptake
where the corrected uptake for Tc-99m-DTPA is determined by the same method as the I131
uptake:
2
Uptake = 1-2 minute background subtracted kidney counts x (kidney depth) x 100
preinjection counts - postinjection counts
Sch8-3
Total and Differential GFR's
Glomerular filtration rates can be calculated by multiplying the filtration fraction with the ERPF.
Right GFR = right FF x right ERPF
Left GFR = left FF x left ERPF
The global GFR is the sum of the differential GFR's.
Total GFR + right GFR + left GFR
Normal Total GFR
The normal total GFR is a normal total GFR of 120 adjusted to the patient's body surface area.
Normal total GFR = 120 x BSA (sq m)/1.73 sq m
where 1.73 square metres is a standard body surface area.
Tc-99m-DTPA Individual Kidney Contributions
Individual kidney contributions are determined from the 1 to 2 minute background subtracted
kidney counts.
Left kidney contribution =

x 100
Right kidney contribution =

x 100
Bladder Analysis
The Schlegel bladder protocol determines the voided, residual, and total volumes and returns.
Knowing the prevoid bladder counts, postvoid bladder counts, and the voided urine volume,
the residual urine volume can be determined.
voided volume (ml) x postvoid net bladder counts

Residual volume (ml) =
prevoid net bladder counts - postvoid net bladder counts
Where the pre and postvoid net bladder counts are determined from bladder and background
ROI's drawn on the pre and postvoid images of the bladder.
prevoid background x prevoid bladder
prevoid bladder counts area

Prevoid net bladder counts = -
counts
prevoid background area
Sch8-4
postvoid background x postvoid bladder
Postvoid net bladder counts = postvoid bladder - counts area
counts postvoid background area
The total urine volume then is the sum of the voided and residual volumes.
Total volume (ml) = voided volume (ml) + residual volume (ml)
The actual percentage of the injected dose voided is determined from the measured voided
urine volume, the activity in the injected dose and in a sample of urine (average urine activity).
This percentage is referred to as the voided return.
average urine activity x 100
Voided return (%) = amount of I131 hippuran injected
where
average urine concentration x voided volume (ml)
average urine activity = in a 2.5 ml sample
2.5
and the
average urine
concentration (reading 1 + reading 2 + reading 3)
in a 2.5 ml sample = - background reading
3
Readings 1, 2, and 3 are the dose calibrator readings of a 2.5 ml undiluted urine sample. The
background reading is the dose calibrator reading of the background.
The per cent of the I131 hippuran dose remaining in the bladder is referred to as the residual
return, and it can be determined from a ratio.
voided return (%) x residual volume (ml)

Residual return (%) = voided volume (ml)
The total percent of the dose excreted is the sum of the voided and residual returns.
Total return (%) = voided return (%) + residual return (%)
Sch8-5
Sch8-6
9. REFERENCES
1. Schlegel JU and Hamway SA: Individual renal plasma determination in two minutes. J Urol
116:282, 1976.
2. Brodkey MJ, Schlegel JU and Derouen TA: Determination of renal plasma flow using the gamma
scintillation camera. Invest Urol 14: 417, 1977.
3. Schlegel JU, Halikiopoulos HL and Prima R: Determination of filtration fraction using the gamma
scintillation camera, J Urol 122:447-450,1979.
4. Schlegel JU and Bakule PT: A diagnostic approach in detecting renal and urinary tract disease, J
Urol 104:2-10, 1970.
5. Lang E, editor: International Perspectives in Urology: Current concepts in uroradiology, Williams

and Wilkins, 1986, pp 1-36.
6. Tonnesen KH, Munck O, Hald T, Mogensen P, Wolf H: Influence on the renogram of variation in skin to
kidney distance and the clinical importance hereof. Presented at the International Symposium on
Radionuclides in Nephrology, Berlin, April 1974.
7. Boyd E, Growth of the Surface Area of the Human Body, U. of Minnesota Press, 1935, p. 132.
8. Chachati A, Meyers A, Godon JP and Rigo P: Rapid method for the measurement of differential
renal function: validation. J Nucl Med 28: 829-836, 1987.
9. Hammes RJ, Rowe BR, Decorah MA et al: Quality control of Tc-99m-DTPA used for GFR studies. J
Nucl Med 29: 980 (scientific exhibit), 1988.
Sch9-1
Sch9-2
APPENDIX A - DATASETS SAVED
The following datasets are created and stored during processing.
HSUM15 I131 hippuran summed 1-5 minute static image
HSUM14 I131 hippuran summed 1-4 minutes static image
HRKROI I131 hippuran right kidney ROI
HRKROI.C1 I131 hippuran right kidney curve
HRBSCRV I131 hippuran right kidney background subtracted curve
HRBSCPM I131 hippuran right kidney background subtracted curve in
counts per minute vs minutes
HRBSCVM I131 hippuran right kidney background subtracted curve in
counts vs minutes
HLKROI I131 hippuran left kidney ROI
HLKROI.C1 I131 hippuran left kidney curve
HLBSCRV I131 hippuran left kidney background subtracted curve
HLBSCPM I131 hippuran left kidney background subtracted curve in
HLBSCVM I131 hippuran left kidney background subtracted curve in
counts vs minutes
HBROI I131 hippuran left kidney background ROI
HBROI.C1 I131 hippuran left kidney background curve
HR15ROI I131 hippuran 15 minute right kidney ROI
HL15ROI I131 hippuran 15 minute left kidney ROI
HB15ROI I131 hippuran 15 minute background ROI
HR25ROI I131 hippuran 25 minute right kidney ROI
HL25ROI I131 hippuran 25 minute left kidney ROI
HB25ROI I131 hippuran 25 minute background ROI
TSUM13 Tc-99m-DTPA summed 1-3 minute static image
TRKROI Tc-99m-DTPA right kidney ROI
TRKROI.C1 Tc-99m-DTPA right kidney curve
TRBSCRV Tc-99m-DTPA right kidney background subtracted curve
TRBSCPM Tc-99m-DTPA right kidney background subtracted curve in
TRBSCVM Tc-99m-DTPA right kidney background subtracted curve in
counts vs minutes
TLKROI Tc-99m-DTPA left kidney ROI
TLKROI.C1 Tc-99m-DTPA left kidney curve
TLBSCRV Tc-99m-DTPA left kidney background subtracted curve
TLBSCPM Tc-99m-DTPA left kidney background subtracted curve in counts
per minute vs minutes
TLBSCVM Tc-99m-DTPA left kidney background subtracted curve in counts
vs minutes
TBROI Tc-99m-DTPA left kidney background ROI
TBROI.C1 Tc-99m-DTPA left kidney background curve
BLADROI1 Prevoid bladder ROI
BLADROI2 Prevoid background ROI
BLADROI3 Postvoid bladder ROI
BLADROI4 Postvoid background ROI
SCHL DATA Scratchpad
Note: If only one kidney was processed, the datasets for the missing kidney will not be
created.
SchA-1
SchA-2
APPENDIX B - DESCRIPTION OF SCRATCHPAD
This is a description of the scratchpad registers used by the
Schlegel protocols. These registers are saved as the scratchpad
dataset SCHL DATA.
Hippuran Tc-99m-DTPA Description
@S1 choice of acquisition -
1 = I131 hippuran
2 = 15 minute static
3 = 25 minute static
4 = bladder (I131 hippuran)
5 = Tc-99m-DTPA
6 = Tc-99m-DTPA and hippuran
@S2 short bladder processing completion flag (if
Tc-99m-DTPA present)
@S3 Tc-99m-DTPA minutes completion flag
@S4 entered patient information flag
@S5 I131 hippuran processing completion flag
@S6 I131 hippuran reframe flag
@S7 I131 hippuran minutes completion flag
@S8 Tc-99m-DTPA processing completion flag
@S9 bladder processing completion flag
@S10 patient height(cm)
@S11 patient weight(kg)
@S12 auto/man flag 1=auto,2=manual
@S13 patient age
@S14 systolic blood pressure
@S15 diastolic blood pressure
@S16 I131 hippuran dose(mci)
@S17 state of hydration 1=yes, 2 = no
@S20 Tc-99m-DTPA dose (mci)
@S21 15 minute processing completion flag
@S22 15 & 25 minute ROI dataset counter
@S23 25 minute processing completion flag
@S24 holds answer to reprocess 15/25 minute ROI menu
@S25 indicates which kidneys are being processed
1 = right only
2 = left only
3 = both
@S26 user response to change ROI question
1 = manipulate ROI (RMAN)
2 = modify ROI (RMOD)
3 = accept ROI as displayed
@S27 Tc-99m-DTPA ROI dataset counter
@S28 L-R-B Tc-99m-DTPA ROI counter
@S29 L-R-B 15/25 minute ROI counter
@S30 @S130 right background subtracted 1-2 min counts

@S31 @S131 left background subtracted 1-2 min counts
@S32 @S132 total 1-2 min background subtracted counts
@S35 patient weght in grams
@S36 intermediate calculation - BSA
@S37 BSA
SchB-1
@S38 right kidney depth
@S39 left kidney depth
@S40 @S140 pre syringe counts
@S41 @S141 one minute pre syringe counts
@S46 @S146 acq time of pre syringe static
@S51 @S151 right uptake
@S52 @S152 left uptake
@S53 total ERPF
@S54 right ERPF
@S55 left ERPF
@S56 30 minute predicted return of injected I131 hippuran
(compare with total bladder return in bladder analysis.
@S57 @S157 right kidney % contribution
@S58 @S158 left kidney % contribution
@S59 expected normal ERPF; ERPF of 600 normalized to
the individual's BSA.
@S60 expected return for a person with a ERPF = 600
and a BSA = 1.73. Always equals 68.
@S62 @S162 Right background subtracted counts - 1st minute
@S63 @S163 Right background subtracted counts - 3rd minute
@S64 Right background subtracted counts - 4th minute
@S65 @S165 Right background subtracted counts - 5th minute
@S73 @S173 Total time of right background subtracted curve
@S74 @S174 Time to peak of right background subtracted curve
@S82 @S182 Left background subtracted counts - 1st minute
@S83 @S183 Left background subtracted counts - 3rd minute
@S84 Left background subtracted counts - 4th minute
@S85 @S185 Left background subtracted counts - 5th minute
@S93 @S193 Total time of left background subtracted curve
@S94 @S194 Time to peak of left background subtracted curve
SchB-2
@S153 total GFR
@S154 right GFR
@S155 left GFR
@S156 normal GFR; GFR of 120 normalized to the individual's
BSA
@S159 right FF
@S160 left FF
@S100 15 minute right kidney ROI pixels
@S101 15 minute right kidney ROI counts
@S102 15 minute left kidney ROI pixels
@S103 15 minute left kidney ROI counts
@S104 15 minute background ROI pixels
@S105 15 minute background ROI counts
@S106 15 minute right kidney background subtracted counts
@S107 15 minute left kidney background subtracted counts
@S108 15 minute total background subtracted counts
@S109 15 minute right kidney % contribution
@S110 15 minute left kidney % contribution
@S112 total acquisition time for REN FLWI
@S113 flag to indicate that dataset H15MIN exists
@S115 25 minute right kidney ROI pixels
@S116 25 minute right kidney ROI counts
@S117 25 minute left kidney ROI pixels
@S118 25 minute left kidney ROI counts
@S119 25 minute background ROI pixels
@S120 25 minute background ROI counts
@S121 25 minute right kidney background subtracted counts
@S122 25 minute left kidney background subtracted counts
@S123 25 minute total background subtracted counts
@S124 25 minute right kidney % contribution
@S125 25 minute left kidney % contribution
@S128 flag to indicate that dataset H25MIN exists
@S200 volume of urine voided at 30 minutes (ml)
@S201 reading 1 of 2.5 ml urine sample
@S204 background reading of urine sample
@S205 dose injected (same units as urine sample readings)
@S210 area of prevoid ROI
@S211 counts in prevoid ROI
@S212 area of prevoid background ROI
@S213 counts in prevoid background ROI
@S214 total prevoid counts : prevoid ROI counts
minus normalized background counts
@S215 area of postvoid ROI
@S216 counts in postvoid ROI
@S217 area of postvoid background ROI
@S218 counts in postvoid background ROI
@S219 total postvoid counts : postvoid ROI counts
minus normalized background counts
SchB-3
@S220 average urine concentration
@S221 average urine activity (in volume voided)
@S222 residual volume (ml)
@S223 total volume (ml)
@S224 % return voided
@S225 % return residual
@S226 % return total
@S230 % of prevoid counts remaining in bladder
(if Tc-99m-DTPA present)
@S250 user response to Schlegel review menu
@S251 user response to Schlegel processing menu
SchB-4
APPENDIX C - HEIGHT AND WEIGHT CONVERSION TABLES
HEIGHT WEIGHT
centimetres feet Inches pounds kilograms
152.4 5 0 100 45.4
153.7 5 0 12 101 45.9
155 5 1 102 46.3
156.2 5 1 12 103 46.8
157.5 5 2 104 47.2
158.8 5 2 12 105 47.7
160 5 3 106 48.1
161.3 5 3 12 107 48.6
162.3 108 49.0
5 4 109 49.5
163.8 5 4 12 110 49.9
165.1 5 5 111 50.4
166.4 5 5 12 112 50.8
168 5 6 113 51.3
168.9 5 6 12 114 51.8
170.2 5 7 115 52.2
171.5 5 7 12 116 52.7
172.7 5 8 117 53.1
174.0 5 8 12 118 53.6
175.3 5 9 119 54.0
176.5 5 9 12 120 54.5
177.8 5 10 121 54.9
179.1 122 55.4
5 10 12 123 55.8
180.3 5 11 124 56.3
181.6 5 11 12 125 56.8
182.9 6 0 126 57.2
184.2 6 0 12 127 57.7
185.4 6 1 128 58.1
186.7 6 1 12 129 58.6
188.0 6 2 130 59.0
189.2 6 2 12 131 59.5
190.5 6 3 132 59.9
191.8 133 60.4
6 3 12 134 60.8
193.0 6 4 135 61.3
194.3 6 4 12 136 61.7
195.6 6 5 137 62.2
196.9 6 5 12 138 62.7
198.1 6 6 139 63.1
SchC–1
APPENDIX C - HEIGHT AND WEIGHT CONVERSION TABLES (CONTINUED)
WEIGHT WEIGHT
pounds kilograms pounds kilograms

140 63.6 180 81.7
141 64.0 181 82.2
142 64.5 182 82.6
143 64.9 183 83.1
144 65.4 184 83.5
145 65.8 185 84.0
146 66.3 186 84.4
147 66.7 187 84.9
148 67.2 188 85.3
149 67.6 189 85.8
150 68.1 190 86.3
151 68.6 191 86.7
152 69.0 192 87.2
153 69.5 193 87.6
154 69.9 194 88.1
155 70.4 195 88.5
156 70.8 196 89.0
157 71.3 197 89.4
158 71.7 198 89.9
159 72.2 199 90.3
160 72.6 200 90.8
161 73.1
162 73.5
163 74.0
164 74.5
165 74.9
166 75.4
167 75.8
168 76.3 Conversion Factors
169 76.7 1 centimetre = 0.394 inch
170 77.2 1 foot = 30.5 centimetres
171 77.6
172 78.1 1 kilogram = 2.20 pounds
173 78.5 1 pound = 0.454 kilogram
174 79.0
175 79.5
176 79.9
177 80.4
178 80.8
179 81.3
SchC–2
APPENDIX D - PATIENT INFORMATION FORM
Patient name
Patient age (years) Blood pressure
Patient height (cm) Patient sex
Patient weight (kg) Hydrated?
Transplant or two kidney patient?
Hippuran dose injected (mCi)
Tc-99m - DTPA dose injected (mCi)
Bladder Analysis
Time of hippuran injection
Volume of urine voided (ml)
Time post-injection patient voided (minutes)
First dose calibrator reading of urine sample
Second dose calibrator reading of urine sample
Background dose calibrator reading
Injected dose (same units as urine sample readings)
PLEASE REFER TO SECTION 4 OF THE SCHLEGEL MANUAL FOR MORE INFORMATION
SchD–1
SchD–2
GATES RENAL PROTOCOL
August 18th, 1989

CONTENTS

Pharmaceutical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 - 1
Collimator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 - 1
Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 - 1
Dosage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 - 1
Injection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 - 1
2. HOW TO USE THE SYRINGE HOLDER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 - 1

4. PROCESSING PROTOCOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 - 1
5.1 Generate Tc-99m-DTPA One Minute Count Totals . . . . . . . . . . . . . . . . . 5 - 1
6. REVIEW MODES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 - 1
TC-99M-DTPA Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 - 1
TC-99M-DTPA One Minute Count Totals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 - 2
Total GFR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 - 1
Differential GFR's . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 - 2
Normalized Total GFR's . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 - 2
Age Adjusted, Normalized GFR Values . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 - 2
8. REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 - 1
APPENDIX A - DATASETS SAVED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A - 1
APPENDIX B - DESCRIPTION OF SCRATCHPAD . . . . . . . . . . . . . . . . . . . . . . B - 1
APPENDIX C - HEIGHT AND WEIGHT CONVERSION TABLES . . . . . . . . . . C - 1
APPENDIX D - PATIENT INFORMATION FORM . . . . . . . . . . . . . . . . . . . . . . . . D - 1
Pharmaceutical
Use Tc-99m-DTPA, for the Gates' renal protocol.

Some variability occurs between different preparations of Tc-99m-DTPA (see Section 8 - Reference 1).
The Tc-99m-DTPA package insert suggests that it be used within one hour for GFR determinations.
Check the Tc-99m-DTPA for purity also. The presence of TcO4 in Tc-99m-DTPA decreases GFR values
exponentially by as much as 26%. (5)
Collimator
A medium energy, general purpose (MEGP) collimator should be used with Tc-99m-DTPA.
The medium energy collimator is preferred by Dr. Gates since it allows no septal penetration. A low energy
high resolution (LEHR) collimator could also be used.
Because of septal penetration a low energy general purpose (LEGP) collimator would image the counts in
the pre syringe static higher than they actually are. These higher counts would affect the GFR calculation.
Patient Positioning
Patients are usually in a supine position with the detector placed under the imaging table.
For transplant patients, the patient should be positioned supine with the detector placed over the patient's
abdomen. Use ultrasound or CT to estimate mid-plane kidney depth for transplant patients.
Dosage
For adults, Dr. Gates recommends using 2-3 millicuries (80-120 MBq) of Tc-99m-DTPA.
Injection
If the Tc-99m-DTPA dose is being injected through IV tubing, it should be adequately flushed.
Gat1-1
Gat1-2
2. HOW TO USE THE SYRINGE HOLDER
The syringe holder is used to support the syringe for a static image pre- and post-injection.
For the Gates renal protocol, the Gates' Adapter should be used with the syringe holder.
When you are ready to image the syringe, place the syringe holder on the same table as the one that will be
used for the dynamic acquisition. Position the detector underneath this table.
For a transplant patient, place the syringe holder on the camera face.
clip
centrally
located
3cc Syringe Flange
GATES Adapter
30 cm
Turn the syringe holder on its side and position the Gates Adapter on the syringe holder as illustrated. Lay
the syringe horizontally in the Adapter. The syringe will be a distance of 30cm from the bottom of the syringe
holder.
The attenuator plate should not be used with the syringe holder for the Gates' method.
Gat2-1
Gat2-2
RETURN
To invoke the Gates Renal Protocol, type `GATES' and press .
GATES RENAL PROTOCOL

[ 1 ] Acquisition
[ 2 ] Processing
[ 3 ] Review
[ 0 ] Exit
When either 1, 2 or 3 are selected, a patient selection protocol will be invoked to select or
create a patient. If option 1 is selected, a new patient can be created or an existing patient can
be selected. With options 2 and 3 only patient selection is allowed.
Once patient selection/creation has been completed, the study GATES RENAL will be created
or selected.
Selecting option 1 calls the acquisition protocol, GATESACQ. Selecting option 2 calls the
processing protocol, GATESPROCESS. Selecting option 3 calls the review protocol,
GATESREVIEW.
Upon entering the acquisition protocol, the system type is determined. If the system is a
Maxxus the following screen is displayed:
[ 1 ] Detector 1
[ 2 ] Detector 2
If the technetium energy correction file TcCorr does not exist, the form for ASES will be
SEND FORM
displayed and you will need to select the appropriate energy correction file. Press
to continue.
The acquisition protocol will then set up the following three acquisitions:
This is a 64 x 64, word mode static image of the syringe before injection. The
acquisition will terminate by time, which is set for 3 seconds. Since the counts from
this image are extrapolated to one minute, the acquisition time can be modified if
necessary. The resolution can be changed to 128 x 128.
Gat3-1
This is a 64 x 64, word mode dynamic acquisition, 15 seconds per frame for 24 frames
(6 minutes). The frame rate can be changed as long as it can be evenly divided into 60
seconds. However, it is recommended to keep the total number of frames below 150
to avoid display memory problems. The resolution can be changed to 128 x 128.
Note: You can acquire this dataset in byte mode if you desire, but you will need to
convert it to word mode and rename it back to REN FLWI before it can be processed.
3. Static dataset - PST SYRT
This is a 64 x 64, word mode static image of the syringe after the dynamic acquisition
is complete. The acquisition will terminate by time, which is set for 3 seconds. Since
the counts from this image are extrapolated to one minute, the acquisition time can
be modified if necessary. The resolution can be changed to 128 x 128.
The following form will then be displayed.
ORGP––––––––––––––––––––––––––––––––––––––––GATES RENAL PROTOCOL

Height (cm) :
Weight (kg) :
Age :
Dose (mci) :
Type in the patient's height in centimetres, weight in kilograms, method of determining kidney
depth (automatic or manual), and age in years. This information is required by the processing
protocol.
If the manual method of determining kidney depth is chosen, kidney depths should be
determined by ultrasound or CT. The kidney depth values are the mid-plane values.
If the automatic method of determining kidney depth is chosen, kidney depths will be
determined by the formulas of Tonnesen, et al.
The patient's blood pressure, dose injected in millicuries, and state of hydration are optional. If
these values are entered on the form, they will be displayed on the final review screens with the
calculated results.
SEND FORM
These values will be transferred to the scratchpad.
Press ENERGY to check the spectrum. When you are satisfied that the spectrum is in the
correct setting, press CAMERA to return to camera mode.
The first acquisition, which is the static image of the syringe before injection, will be all set up.
Place the syringe holder on the same table as the one that will be used for the dynamic
acquisition. Position the detector under the table. For a transplant patient, place the syringe
holder on the camera face.
Gat3-2
Turn the syringe holder on its side and position the Gates Adapter on the side of the syringe
holder. (Refer to Section 2 for an illustration.) Lay the syringe, containing the Tc-99m-DTPA
dose to be injected, horizontally in the syringe holder.
When the syringe holder and detector are properly positioned, press ACQ START to start the
static acquisition.
Record the time when the pre syringe static was acquired.
When the static acquisition is complete, the system will automatically set up the second
acquisition. This will be the dynamic acquisition.
Position the patient supine with the detector under the table. The patient's kidneys should be
centered in the field of view.
For a transplant patient, position the patient supine with the detector above the patient. Have
the transplant kidney centered in the field of view.
When the patient, detector, and table are properly positioned, inject the patient and press
ACQ START to start the dynamic acquisition.
Record the time when the dynamic acquisition was started.
Record the time when the dynamic acquisition is complete.
When the dynamic acquisition is complete, the system will automatically set up the third
acquisition. This will be the static image of the empty syringe. This image is used to estimate
the residual activity in the syringe.
Position the syringe holder on the table used for the dynamic acquisition, as before. Position
the detector under the table. For a transplant patient, place the syringe holder on the camera
face.
Position the empty syringe in the Gates Adapter.
ACQ START
When the syringe holder and detector are properly positioned, press to start the
post syringe static acquisition.
Record the time when the post syringe static was acquired.
When the acquisitions are all through, you will see the following message on the alphanumeric
screen:
Enter time (min) from pre syringe acq to start of dynamic

? :
Enter the time in minutes between the pre syringe acquisition and the start of the dynamic
SEND FORM SEND FORM
acquisition and press . If there was no delay, just press to continue.
Usually the delay between the pre syringe acquisition and the injection will take 5 minutes.
Delays greater than 5 minutes will correct the pre syringe counts downward.
You will then see a second message on the alphanumeric screen:
Enter time (min) from end of dynamic to post syringe acq

? :
Gat3-3
Enter the time in minutes between the completion of the dynamic acquisition and the post
SEND FORM SEND FORM
syringe acquisition and press . If there was no delay, just press to
continue.
Usually the delay between the completion of the dynamic acquisition and the post syringe
acquisition will take 5 minutes. Delays greater than 5 minutes will correct the post syringe
counts upward.
The patient information stored in the scratchpad will be saved as a dataset. The name of the
scratchpad dataset is GATES DATA.
Gat3-4
The Gates processing protocol can be invoked from the GATES protocol via menu option `2'.
You can also access the processing protocol by selecting the patient and study to be processed and typing
`GATESPROCESS'.
Gates Renal Processing

1 Tc–99m–DTPA analysis (GFR)
Enter appropriate option & press SEND FORM key.
? :
Option 1 will determine the individual kidney contributions and the global and differential GFR's.
Option 2 will normalize the background subtracted kidney curves to counts versus minutes and generate
one minute count totals for the 6 minutes of the dynamic acquisition.
ESCAPE
To exit the protocol, press .
This section deals with option 1. Section 5 discusses the one minute count totals; and Section 6 describes
the review modes.
SEND FORM
Enter `1' and press to perform Tc-99m-DTPA analysis.
If the dataset REN FLWT is byte mode, you will be informed of this and exit the protocol. Convert this dataset
to word mode and rename it back to REN FLWT and then it can be processed.
The protocol will first check to make sure the scratchpad exists and contains the patient information. If the
scratchpad does not exist, it will be created and you will be prompted to enter the patient information as
described in the acquisition protocol section. If the scratchpad exists but the patient information is missing,
you will be prompted to enter the patient information.
The protocol will then perform some housekeeping and delete previously processed datasets if they exist.
The dynamic dataset REN FLWT will be displayed in quadrant 4, and a 1-6 minute summed image will be
created in quadrant 1.
You will then be prompted to outline the kidney and background ROI's on the composite image in quadrant
1. The ROI's will be duplicated on the dynamic dataset in quadrant 4.
Since imaging was done posteriorly, if this is a two kidney patient, the right kidney will be on the right side of
the image.
POSN TRACE JOIN ERASE

Use , , and to outline the right kidney on the 1-6 minute summed image in
END
quadrant 1. Press twice to continue.
Gat4-1
END POSN TRACE JOIN ERASE

Press once before pressing , , or when the RIRR form for outlining
the right kidney is displayed.
END
Pressing in this way will notify the protocol that you only want to process the left kidney. You
will not have to outline the right kidney or right background region. Everything in the processing
and review protocols from this point on will be in terms of the left kidney.
If you are processing the right kidney, the next message will be displayed:
Outline background ROI near lower outer margin of right kidney.

Use , , and to draw the right kidney background ROI on the 1-6 minute
summed image in quadrant 1. Place the semilunar background ROI near the lower outer margin of
END
the kidney as illustrated. Press twice to continue.
In a similar manner, outline the left kidney and background region when prompted.
END POSN TRACE JOIN ERASE

Press once before pressing , , or when the RIRR form for outlining
the left kidney is displayed.
END
Pressing in this way will notify the protocol that you only want to process the right kidney. You
will not have to outline the left kidney or left background region. Everything in the processing and
Background ROI's
Gat4-2
If the manual method of determining kidney depth was chosen, you will see the following message:
Enter the mid-plane right kidney depth in centimeters as determined by ultrasound or CT. Press
SEND FORM
to continue.
Likewise, you will be prompted to enter the left mid-plane kidney depth in centimeters. Press
SEND FORM
to continue.
If only one kidney is being processed, and the manual method of determining kidney depth was
chosen, you will only be prompted to enter the kidney depth for that kidney.
The protocol will then calculate results. The bottom half of the display will be cleared and the patient
information and GFR Report will be displayed.
At the end of processing, the review menu will be displayed.
Gates Renal Review

4 Exit
Enter menu choice & press SEND FORM key
? :
Option 1 displays patient information, individual kidney contributions and the GFR report.
Option 2 displays the background subtracted kidney curves as counts versus minutes; times to peak; and
individual kidney one minute count totals.
These review modes are available at any time after the data has been processed. Type in
`GATESPROCESS' to initiate the Gates renal protocols and then select Òption 3 - Review processed data'.
You can also access review modes by typing in `GATESREVIEW' to initiate the Gates review protocol.
Gat4-3
Gat4-4
Generate Tc-99m-DTPA One Minute Count Totals
The Tc-99m-DTPA analysis will generate background subtracted individual kidney curves.
totals derived from these curves are used by the protocol to estimate the total GFR and will be
displayed in the Tc-99m-DTPA analysis review.
The Tc-99m-DTPA analysis portion of the processing protocol needs to be done before this
option can be run.
Select the appropriate patient and Gates Renal study.
GATESPROCESS
RETURN
and press .
Gates Renal Processing
1 Tc–99m–DTPA analysis (GFR)

Enter appropriate option & press SEND FORM key.
? :
SEND FORM
The protocol will first check to make sure that the Tc-99m-DTPA analysis has already been
done. If it hasn't, you will see the message:
Tc–99m–DTPA data has not been completely processed
If the Tc-99m-DTPA analysis has been completed, the protocol will perform some
count totals for the first 6 minutes will be determined from the background subtracted curves.
Gat5-1
15, or 30 minutes. If the acquisition did extend to any of these times, one minute count totals
will be determined for them as well.
right corner.
If two kidneys were processed, a legend indicating which are the right and left kidney curves
will be displayed below the curve axes.
If they are there, left and right one minute count totals will be displayed for the 9-10th,
14-15th, and 29-30th minutes.
At the end of processing, the review menu will be displayed:
Gates Renal Review

4 Exit
Enter menu choice & press SEND FORM key
? :
Gat5-2
6. REVIEW MODES
methods available to access the Gates review protocol.
1. The Gates review protocol can be invoked from the GATES protocol via menu
option `3'.
2. You can also access the review modes by typing in `GATESREVIEW' to initiate the
Gates review protocol.
3. Type in `GATESPROCESS' to initiate the Gates renal protocols and then select
Òption 3 - Review processed data'.
Gates Renal Review

4 Exit

? :
Option 1 displays patient information, individual kidney contributions, and the GFR
report.
Option 2 displays the background subtracted kidney curves as counts versus
This review mode displays patient information, individual kidney contributions, and the GFR
report.
centimeters, weight in kilograms, and age in years will be displayed, and, if it was entered, so
will the patient's blood pressure, injected dose in millicuries and state of hydration. The
patient's body surface area in square meters, and left and right kidney depths in centimeters
will be displayed below this information. The one minute pre syringe counts (SYR CTS), one
minute post syringe counts (PSR CTS), and one minute syringe counts (1 MIN SYR CTS) will
be displayed in this same area.
Gat6-1
The GFR report will be displayed below the patient information.
This report includes the global and differential 2 to 3 minute counts, per cent contributions, and
global and differential GFR's.
The normalized total GFR (NORM GFR) will be displayed under the total GFR. The normalized
total GFR is the total GFR times a standard body surface area of 1.73 divided by the patient's
body surface area.
If the patient's age is between 20 and 60 years, the mean normal GFR (MEAN NORM FOR
AGE) and the lower limit for GFR (LOWER LIMIT FOR AGE) for the related age group (nearest 5
years) will also be displayed.
If only one kidney was processed, the 2-3 minute counts, per cent contribution, and GFR
value for the missing kidney will appear as zeroes on the report.
Tc-99m-DTPA One Minute Count Totals

Left and right kidney one minute count totals will be displayed for the 6 minutes of the dynamic
acquisition. The total 2-3 minute counts will also be displayed.
If they are there, the left and right one minute count totals will be displayed for the 9-10th
minute, 14-15th minute, and 29-30th minute.
appear as zeroes.
Gat6-2
The Gates renal protocol provides a nuclear camera based method of estimating glomerular
filtration rate (GFR) using Tc-99m-DTPA. This method makes it possible to determine total,
as well as individual, kidney GFR by a radionuclide technique that takes only six minutes of the
patient's time, and requires neither blood nor urine samples. Individual kidney per cent
contributions, normalized total GFR, and age adjusted, normalized GFR values are also
determined.
This method has been validated on adults (2), and can be used with both two kidney and
transplant patients.
Total GFR
The total GFR is estimated from the renal uptake of Tc-99m-DTPA 2-3 minutes following
radiotracer arrival in the kidneys.
The 2-3 minute uptake of Tc-99m-DTPA within each kidney is proportional to the glomerular
filtration rate. (1)
A linear equation of the form:
Y = AX + B
relates total GFR to the renal uptake of Tc-99m-DTPA, with Y equal to total GFR and X equal
to the renal uptake of Tc-99m-DTPA as a percentage of the administered dose at the 2-3
minute time interval following tracer arrival within the kidneys.
The coefficients A and B were determined by linear regression analysis of data comparing the
percent renal uptake of Tc-99m-DTPA with 24 hour creatinine clearances.
With the coefficients in place, the formula for total GFR becomes:
Total GFR = 9.81270 x renal uptake - 6.82519
To determine the 2-3 minute uptake, area normalized background counts are subtracted
from the radionuclide counts within each kidney. The background subtracted counts are then
-ux
corrected for soft tissue attenuation by dividing by the factor e , where x is the mid-plane
kidney depth in centimetres and u is the linear attenuation coefficient of Tc-99m in soft tissues
(.153).
Kidney depths can be measured by CT or ultrasound, or they can be estimated by the formulas
of Tonnesen et al (6).
Right kidney depth (cm) = 13.3 x (weight/height) + .7
Left kidney depth (cm) = 13.2 x (weight/height) + .7
where weight is in kilograms and height is in centimetres.
Finally, the renal uptake of Tc-99m-DTPA is calculated as a percentage of the administered
dose by dividing by the injected counts (preinjected counts - postinjection counts) and
multiplying by 100. Pre and post injection counts are determined from pre and post injection
static acquisitions of the syringe.
Gat7-1
In its final form, the equation for total GFR is:
-ux -ux
Rt kid bk sub cts/e + Lt kid bk sub cts/e
Total GFR = 9.81270 x x 100 -6.82519
preinjection cts - postinjection cts
where Rt kid bk sub cts and Lt kid bk sub cts refer to the right and left kidney 2-3 minute
background subtracted counts.
Differential GFR
Individual kidney GFR values can be determined by multiplying the total GFR by the fractional
uptake of each kidney at 2 - 3 minutes. The fractional uptakes are determined from the 2-3
minute background subtracted kidney counts.

Left fractional uptake =
Right kidney 2-3 min background subtracted counts

Right fractional uptake =
Left GFR = total GFR x left fractional uptake
Right GFR = total GFR x right fractional uptake
Left kidney contribution = left fractional uptake x 100
Right kidney contribution = right fractional uptake x 100
Normalized Total GFR
The normalized total GFR is the total GFR normalized to a standard body surface area of 1.73
square metres.
1.73
Normalized total GFR = total GFR *
BSA
The Boyd formula is used to calculate body surface area (BSA). (7)
.3 .7285 - .0188 log weight

BSA (sq m) = .0003207 x (height ) x (weight )
where height is in centimetres and weight is in grams.
Age Adjusted, Normalized GFR Values
Age adjusted, normalized GFR values are provided for patients between the ages of 20 and 60.
These values include a mean normal value and a lower limit (standard error of the 5th
percentile) value for the related age group. The related age group is determined by rounding
off the patient's age to the nearest value that is evenly divisible by 5.
The age adjusted values are based on age corrected inulin clearances for individuals between
the ages of 20 and 60. These values are independent of sex. (3)
Gat7-2
8. REFERENCES
1. Gates GF: Glomerular filtration rate: estimation from fractional renal accumulation of
99m-Tc-DTPA (stannous). Am J Roentgenol, 138: 565, 1982.
2. Gates GF: Split renal function testing using Tc-99m DTPA: A rapid technique for
determining differential glomerular filtration. Clin Nucl Med 8:400-407, 1983.
3. Gates GF: Computation of glomerular filtration rate with Tc-99m DTPA: An in-house
computer program. J Nucl Med 25: 613-618, 1984.
4. Tauxe WN and Dubovsky EV: Nuclear Medicine in Clinical Urology and Nephrology,
Appleton-Century-Crofts, 1985. Ch. 9, pp 170 - 173.
5. Hammes RJ, Rowe BR, Decorah MA et al: Quality control of Tc-99m DTPA used for
GFR studies. J Nucl Med 29: 980 (scientific exhibit), 1988.
6. Tonnesen KH, Munck O, Hald T, Mogensen P, Wolf H: Influence on the renogram of
variation in skin to kidney distance and the clinical importance hereof. Presented at
the International Symposium on Radionuclides in Nephrology, Berlin, April 1974.
7. Edith Boyd, Growth of the Surface Area of the Human Body, U. of Minnesota Press,
1935, p. 132.
8. Chachati A, Meyers A, Godon JP and Rigo P: Rapid method for the measurement of
differential renal function: validation. J Nucl Med 28: 829-836, 1987.
9. Cuocolo A, Esposito S et al: Renal artery stenosis detection by combined Gates'
technique and captopril test in hypertensive patients. J Nucl Med 30: 51-56, 1989.
Gat8-1
GSUM16 Summed 1-6 minute static image
GRKROI Right kidney ROI
GRKROI.C1 Right kidney curve

GRBROI Right kidney background ROI
GRBROI.C1 Right kidney background curve
GRBSCRV Right kidney background subtracted curve

GRBSCPM Right kidney background subtracted curve in counts per minute vs
minutes
GRBSCVM Right kidney background subtracted curve in counts vs minutes
GLKROI Left kidney ROI
GLKROI.C1 Left kidney curve

GLBROI Left kidney background ROI
GLBROI.C1 Left kidney background curve

GLBSCRV Left kidney background subtracted curve
GLBSCPM Left kidney background subtracted curve in counts per minute vs
minutes
GLBSCVM Left kidney background subtracted curve in counts vs minutes
GATES DATA Scratchpad
If only one kidney was processed, the datasets for the missing kidney will not be created or
saved.
GatA-1
This is a description of the scratchpad registers used by the Gates protocols. These registers
are saved as the scratchpad dataset GATES DATA.
Register Description
@S5 Tc-99m-DTPA processing completion flag
@S6 completed 1 minute count totals
@S10 patient height(cm)
@S11 patient weight(kg)
@S12 auto/manual flag 1 = auto, 2 = manual
@S13 patient age
@S16 dose(mci)
@S17 state of hydration 1 = yes, 2 = no
@S18 pre delay time in minutes
@S19 post delay time in minutes
@S20 patient age rounded off to nearest 5 years
@S25 indicates which kidneys are being processed
1 = right only
2 = left only
3 = both
@S30 right background subtracted 2-3 minute counts
@S31 left background subtracted 2-3 minute counts
@S32 total 2-3 minute background subtracted counts
@S35 patient weight in grams
@S36 intermediate calculation for body surface area
@S37 body surface area
@S38 right kidney depth
@S39 left kidney depth
@S40 pre syringe counts
@S41 one minute pre syringe counts(includes decay correction if needed)
@S42 post syringe counts
@S43 one minute post syringe counts (includes decay correction if needed)
@S45 1 min syringe counts (1 minute pre syringe counts - 1 minute post
syringe counts)
@S46 acquisition time of pre syringe static
@S47 acquisition time of post syringe static
@S48 pre decay correction factor
@S49 post decay correction factor
@S50 right correction factor
@S51 left correction factor
@S52 intermediate GFR calculation
@S53 total GFR
@S54 right GFR
@S55 left GFR
@S57 right kidney % contribution
@S58 left kidney % contribution
GatB-1
@S60 normalized total GFR
@S61 mean normal GFR (age corrected)
@S62 lower limit for GFR (age corrected)
@S70 Right background subtracted counts - 1st minute

@S71 Right background subtracted counts - 2nd minute
@S78 Total time of right background subtracted curve
@S79 Time to peak of right background subtracted curve
@S80 Left background subtracted counts - 1st minute

@S81 Left background subtracted counts - 2nd minute
@S88 Total time of left background subtracted curve
@S89 Time to peak of left background subtracted curve
@S251 User response to processing menu
GatB-2
APPENDIX C -
HEIGHT WEIGHT
HEIGHT AND WEIGHT CONVERSION TABLES
152.4 5 0 100 45.4
153.7 5 0 12 101 45.9
155 5 1 102 46.3
156.2 5 1 12 103 46.8
157.5 5 2 104 47.2
158.8 5 2 12 105 47.7
160 5 3 106 48.1
161.3 107 48.6
5 3 12 108 49.0
162.3 5 4 109 49.5
163.8 5 4 12 110 49.9
165.1 5 5 111 50.4
166.4 5 5 12 112 50.8
168 5 6 113 51.3
168.9 5 6 12 114 51.8
170.2 5 7 115 52.2
171.5 5 7 12 116 52.7
172.7 5 8 117 53.1
174.0 5 8 12 118 53.6
175.3 5 9 119 54.0
176.5 5 9 12 120 54.5
177.8 5 10 121 54.9
179.1 5 10 12 122 55.4
123 55.8
180.3 5 11 124 56.3
181.6 5 11 12 125 56.8
182.9 6 0 126 57.2
184.2 6 0 12 127 57.7
185.4 6 1 128 58.1
186.7 6 1 12 129 58.6
188.0 6 2 130 59.0
189.2 6 2 12 131 59.5
190.5 6 3 132 59.9
191.8 6 3 12 133 60.4
193.0 6 4 134 60.8
135 61.3
194.3 6 4 12 136 61.7
195.6 6 5 137 62.2
196.9 6 5 12 138 62.7
198.1 6 6 139 63.1
GatC-1
WEIGHT WEIGHT

140 63.6 180 81.7
141 64.0 181 82.2
142 64.5 182 82.6
143 64.9 183 83.1
144 65.4 184 83.5
145 65.8 185 84.0
146 66.3 186 84.4
147 66.7 187 84.9
148 67.2 188 85.3
149 67.6 189 85.8
150 68.1 190 86.3
151 68.6 191 86.7
152 69.0 192 87.2
153 69.5 193 87.6
154 69.9 194 88.1
155 70.4 195 88.5
156 70.8 196 89.0
157 71.3 197 89.4
158 71.7 198 89.9
159 72.2 199 90.3
160 72.6 200 90.8
161 73.1
162 73.5
163 74.0
164 74.5
165 74.9
166 75.4
167 75.8
171 77.6
173 78.5 1 pound = 0.454 kilogram
174 79.0
175 79.5
176 79.9
177 80.4
178 80.8
179 81.3
GatC-2
Patient name
Tc-99m - DTPA dose injected (mCi)
Time pre-syringe static acquired
Time dynamic acquisition started
Time dynamic acquisition finished
Time post-syringe static acquired
Time from pre-syringe acquisition to start of dynamic (minutes)
Time from end of dynamic to post-syringe acquisition (minutes)
PLEASE REFER TO SECTION 3 OF THE GATES MANUAL FOR MORE INFORMATION
GatD1
GatD2
TAUXE-DUBOVSKY RENAL PROTOCOL
August 18th, 1989

CONTENTS
Pharmaceutical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 - 1
Collimator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 - 1
Patient Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 - 1
Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 - 1
Dosage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 - 1
Injection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 - 1
3. HOW TO DETERMINE PLASMA, URINE, AND STANDARD COUNTS . . . 3 - 1
Plasma Counts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 - 1
Urine Counts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 - 1
Standard Counts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 - 1
Standard Count Corrections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 - 2
4. PROCESSING PROTOCOL ........................................ 4 - 1
5.1 ERPF Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 - 1
5.2 Bladder Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 - 3
6. REVIEW MODES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 - 1
Hippuran ERPF Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 - 1
Hippuran Bladder Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 - 2
Reframed Data and Normalised Curves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 - 2
Global ERPF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 - 1
Differential ERPF's . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 - 2
Corrected ERPF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 - 2
Bladder Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 - 2
8. REFERENCES .................................................... 8 - 1
APPENDIX A - DATASETS SAVED .................................... A - 1
APPENDIX B - DESCRIPTION OF SCRATCHPAD ...................... B - 1
APPENDIX C - HEIGHT AND WEIGHT CONVERSION TABLES .......... C - 1
APPENDIX D - PATIENT INFORMATION FORM ........................ D - 1

Pharmaceutical
Use I-131 or I-123 hippuran for the Tauxe-Dubovsky renal protocol.

Each new lot of hippuran should be tested for free iodine content by thin layer chromatography, and should
contain less than 1.5% free iodine. Please refer to the article referenced `Comprehensive renal function
studies with I-131-OIH' for a description of this technique.
Collimator
A high energy collimator should be used with I-131 or I-123 hippuran.

Patient Preparation
It is important that the patient be in a state of normal hydration for imaging.

To insure adequate hydration, patients are routinely given 300-500 ml of fluid to drink 30 minutes before
testing.
Patient Positioning
Patients are usually in a supine position with the detector placed under the imaging table. For transplant
patients, however, the detector is placed over the patient's abdomen.
For bladder imaging, patients should be turned over in a prone position and have the bladder centered in
the imaging field of the detector.
Dosage
Dr. Tauxe and Dubovsky recommends the following doses of hippuran based on age:
50 mci for children less than 1 year
100mmci for children 1 to 6 years old
100 mci per kidney for children 6 to 15 years old
150 mci per kidney for patients older than 15
In children younger than 6 years of age, I-123 hippuran should be used.
Injection
Injections must be adequate and accurate without extravasation.

Read the syringe in the dose calibrator before and after the injection to make sure the whole dose has been
injected.
If a significant portion of the total dose was not injected, corrections must be made to the standard counts to
insure that the calculated results will be accurate. Refer to the section on `How to determine plasma,
standard, and urine counts' for this correction.
TD1-1
TD1-2
RETURN
To invoke the Tauxe Dubovsky Renal Protocol, type 'TAUXE_DUBOVSKY' and press .
TAUXE–DUBOVSKY RENAL PROTOCOL

[ 1 ] Acquisition
[ 2 ] Processing
[ 3 ] Review
[ 0 ] Exit
When either 1, 2 or 3 are selected, a patient selection protocol will be invoked to select or create a patient. If
option 1 is selected, a new patient can be created or an existing patient can be selected. With options 2 and
3 only patient selection is allowed.
Once patient selection/creation has been completed, the study TXDUB RENAL will be created or if present,
selected.
Selecting option 1 calls the acquisition protocol, TXDUBACQ. Selecting option 2 calls the processing
protocol, TXDUBPROCESS. Selecting option 3 calls the review protocol, TXDUBREVIEW.
Please note: This acquisition protocol is set up for I-131 hippuran. This protocol can easily be
modified for use with I-123 hippuran.
Upon entering the acquisition protocol, the system type is determined. If the system is a Maxxus, the
following screen is displayed:
[ 1 ] Detector 1
[ 2 ] Detector 2
Once detector selection for Maxxus has been completed or if it is a single detector system, the appropriate
energy session will be set up for data acquisition.
TD2-1
ORDI––––––––––––––––––––––––––––––––––TAUXE–DUBOVSKY PATIENT INFORMATION

Patient height (cm) :
Patient weight (kg) :
Patient age (yrs) :
Transplant patient? (1=yes,2=no) :
Hippuran dose injected (uci) :
Hydrated? (1=yes, 2=no) :
Patient sex (1=male, 2=female) :
Type in the patient's height in centimetres, weight in kilograms, age in years, and kidney state. This
information is required by the processing protocol.
The patient's blood pressure, dose injected, state of hydration, and sex are optional. If these values are
entered on the form, they will be displayed on the final review screens with the calculated results.
SEND FORM
These values will be transferred to the scratchpad and saved as a dataset. The name of the scratchpad
dataset is TXDUB DATA.
If the hippuran energy correction file I131CORR does not exist, the form for ASES will be displayed and you
SEND FORM
will need to select the appropriate energy correction file. Press to continue.
The acquisition protocol will then set up the following four acquisitions:
Note: You can acquire this dataset in byte mode if you desire, but you will need to convert it to word
mode and rename it back to REN FLWI before processing.
2. Static dataset - PREVOID
This is a 64 x 64, word mode, 60 second static image of the bladder before voiding.
Voiding should take place 30-35 minutes post injection.
3. Static dataset - POSTVOID
This is a 64 x 64, word mode, 60 second static image of the bladder after voiding.
4. Static dataset - INJSITE
This is a 64 x 64, word mode, 60 second static image of the injection site.
The acquisitions will be queued up after they are defined, and the system will be in camera mode.
ENERGY
Press to check the spectrum. When you are satisfied that the spectrum is in the correct setting,
CAMERA
press to return to camera mode.
Position the patient supine with the detector under the table. Have the patient's kidneys centered in the field
of view. For a transplant patient, position the patient supine with the detector above the patient. Have the
transplant kidney centered in the field of view.
TD2-2
ACQ START
Record the time of injection.
When the dynamic acquisition is complete, the system will automatically set up the second acquisition. This
will be the static prevoid bladder image. Have the patient turn over to a prone position and center the
patient's bladder within the field of view.
ACQ START
When the patient is properly positioned press to start the prevoid acquisition.
When the prevoid acquisition is complete, the patient should void. Voiding should take place 30-35
minutes post injection.
Record the time post injection in minutes the patient voided. This information will be needed by the
processing protocol.
After the patient has voided, position the patient as for the prevoid acquisition. The third acquisition, the
postvoid bladder static, will be all set up.
ACQ START
When the patient is properly positioned press to start the postvoid acquisition.
After the postvoid acquisition is complete, the system will then set up the fourth and last acquisition. This is
the static image of the injection site. Its purpose is to check that the whole dose was injected without any
ACQ START
infiltration. Position the detector over the injection site and press to start the acquisition.
When this acquisition is complete, the acquisition protocol will be complete.
The patient's blood should be sampled at the appropriate time.
For children 13 years of age and younger, blood should be sampled between 50 and 60 minutes post
injection, with 53 minutes the optimum sampling time.
For adults, blood should be sampled between 40 and 55 minutes post injection, with 44 minutes the
optimum sampling time.
The blood sample is one purple/lavender stopper tube (7 ml).
Record the time post injection in minutes the patient's blood was sampled. This information will be needed
by the processing protocol.
Before processing the data, you will need to determine the standard, urine, and plasma counts as
described in the next section.
TD2-3
TD2-4
3. HOW TO DETERMINE PLASMA, URINE, AND STANDARD COUNTS
Plasma, urine, and standard counts should be read in a well counter.
The same size well counter tube must be used for the plasma, urine, and standard counts since geometry
affects the final results.
As the following instructions will show, all readings should be performed twice due to the randomness of
decay. The two readings are then averaged to determine the final value.
Plasma Counts
The patient's blood should be sampled at the correct time.
Blood sampling should be between 50 and 60 minutes for children 13 years of age and younger, with 53
minutes being the ideal children's sampling time.
Blood sampling should be between 40 and 55 minutes for an adult greater than 13 years of age, with 44
minutes being the ideal adult sampling time.
The blood sample should be one purple/lavender stopper, or 7 ml, tube. Centrifuge the blood down and put
1 cc of plasma into a well counter tube. Count the 1 cc for 2 minutes and record the counts.
Put 1 cc of plasma into a second well counter tube and count it for 2 minutes. Record the counts.
Average the two plasma well counter readings. The average reading is entered in the processing protocol
as plasma counts.
Urine Counts
The patient should void at the proper time. Voiding should take place 30 - 35 minutes post injection.
After the patient has voided, mix the urine thoroughly since sediment will settle to the bottom of the
container. Pipette 1 cc of the patient's urine into a 100 ml volumetric flask. QS, or fill the flask to the mark with
tap water. Cap the flask and invert to mix thoroughly. Pipette out 1 cc of the diluted urine into a well counter
tube. Count for 2 minutes and record the counts.
Pipette 1 cc of the diluted urine into a second well counter tube and count it for 2 minutes. Record the results.
Average the two urine well counter readings. The average reading is entered in the processing protocol as
urine counts.
Perform a specific gravity measurement on the diluted urine to make sure that the patient was hydrated. The
specific gravity for the diluted urine should be close to 1.00.
Finally, measure the volume of urine voided. Be sure to add 1 cc to the amount measured to replace the 1 cc
withdrawn for the count measurements.
Standard Counts
To prepare the standard stock solution, remove 1.5 cc of hippuran from the vial of hippuran shipped by the
manufacturer. Put into a tube. Using a volumetric pipette, put 1 cc into a 100 ml volumetric flask. QS, or fill to
the mark with tap water, and mix well. Remove 20 cc of the diluted hippuran from the flask and put in a vial.
This is the standard stock solution. Label the vial with the lot number, assay date, and expiration date. The
standard stock solution can be used until that lot of hippuran expires.
The standard counts should be determined when the patient's plasma and urine samples are being
counted.
TD3-1
Withdraw the exact same amount (volume in ml) from the vial of standard stock solution as there is hippuran
in the syringe. Put this amount of standard stock solution into a 10 ml volumetric flask. QS, or fill to the mark
with tap water. Mix thoroughly. Pipette two 1 cc aliquots of the prepared standard solution into two well
counter tubes. Count each for 2 minutes and record the results.
Put 1 cc of the diluted stock solution into a second well counter tube and count for 2 minutes. Record the
results.
Average the two standard count readings. The average reading is entered in the processing protocol as
standard counts.
These two well counter tubes can be used to determine the standard counts for all patients imaged that day.
However, it is important that the tubes are counted at the proper time during the day.
Standard Count Corrections
As noted in the section on acquisition parameters, the syringe should be measured in a dose calibrator
before and after the injection to make sure that the whole dose is injected.
If a significant amount of the dose is not injected into the patient, a correction must be made to the standard
counts to insure that the calculated values are accurate. For a dose of 100, 200 or 300 micro-curies, any
amount greater than 6 or 7 micro-curies remaining in the syringe is significant enough to make the
correction. For a dose of 50 micro-curies, any amount greater than 4 micro-curies remaining in the
syringe is significant.
To make the correction, measure the amount of dose left in the syringe. Divide this amount by the total dose
to find the per cent not injected.
Measure the standard counts as described above. Multiply the standard counts by the per cent not injected.
Subtract this number from the standard counts. Enter this adjusted value for the standard counts in the
processing protocol.
For example, if the total dose was 300 micro-curies and 15 micro-curies remained in the syringe after the
injection, 5 % of the total dose was not injected. If the standard counts measured 500,000, then 5% of
500,000, or 25,000, would need to be subtracted from 500,000. The standard counts entered in the
processing protocol would be 475,000.
TD3-2
Before processing the data, display the dataset INJSITE and check it for infiltration. A bright spot on the
patient's arm in the image indicates infiltration. If the degree of infiltration is slight, the acquired data can still
be processed. If there is significant infiltration, the patient should be rescheduled for another study.
Make sure that the plasma, urine, and standard counts have been determined.
The Tauxe-Dubovsky processing protocol can be invoked from the TAUXE_DUBOVSKY protocol via menu
option `2'.
You can also access the processing protocol by selecting the patient and study to be processed and typing
`TXDUBPROCESS'.
Tauxe–Dubovsky Renal Processing

1 Hippuran analysis (ERPF & bladder analysis)
2 ERPF analysis
3 Bladder analysis
Enter option & press SEND FORM or ESCAPE to exit
? :
Option 1 will determine the global and differential effective renal plasma flow (ERPF), fractional hippuran
excretion, and evaluation of urinary bladder function.
Option 2 will determine global and differential ERPFs'.
Option 3 will evaluate urinary bladder function.
This section deals with option 1. Options 2 and 3 are dealt with in section 5. Section 6 describes the review
modes.
SEND FORM
Enter `1' and press to perform hippuran analysis.
If the dataset REN FLWI is byte mode, you will be informed of this and exit the protocol. Convert this dataset
to word mode and rename it back to REN FLWI and then it can be processed.
The protocol will first check to make sure the scratchpad exists and contains the patient information. If the
scratchpad does not exist, it will be created and you will be prompted to enter the patient information as
described in the acquisition protocol section. If the scratchpad exists but the patient information is missing,
you will be prompted to enter the patient information.
ORDP––––––––––––––––––––––––––––––––––––––––TAUXE–DUBOVSKY RENAL PROTOCOL

Standard counts
Volume
: of urine voided (ml)
Time postinjection patient voided (min)
:
:
Urine counts
Time postinjection blood drawn (min)
:
Plasma counts
: :
TD4-1
SEND FORM
Enter the information and press to continue.
The dynamic dataset REN FLWI will be displayed in quadrant 1 and reframed into 1 minute per frame
images in quadrant 3. A 3 minute summed image will be created and displayed in quadrant 4.
The top half of the display will be cleared and the one minute reframed data will be displayed.
4. The ROI's will be duplicated on the reframed dataset in the quadrant 3.
If the patient is a transplant patient you will see the following message:
Outline transplant kidney on summed image.
POSN TRACE JOIN ERASE END

Use , , and to outline the transplant kidney. Press twice to
continue.
Outline crescent shaped background ROI above transplant kidney.

Use , , and to draw the transplant background ROI. Outline a narrow
ring around the upper portion of the kidney. Be careful to avoid the bladder as illustrated. Press
END
twice to continue.
If the patient is a two kidney patient you will see the following message:
Outline right kidney on summed image.

Use , , and to outline the right kidney. Press twice to continue.
Outline left kidney on summed image.

Use , , and to outline the left kidney. Press twice to continue.
Outline crescent shaped background ROI to left of left kidney.

Use , , and to draw the two kidney background ROI. The two kidney
END
background ROI should be a narrow ring around most of the left kidney as illustrated. Press
twice to continue.
TD4-2
Transplant patient Two kidney patient
Kidney background ROI's
The kidney and background curves will be generated in the upper left quadrant. These curves will be
background subtracted in quadrant 1. The background subtracted curves will be normalised first to counts
per minute vs minutes (quadrant 2) and then to counts vs minutes (quadrant 3).
The display will be cleared to start the bladder analysis portion of the protocol.
Since the ERPF, and some of the bladder calculations which are based on the ERPF, depend on the plasma
sampling time, the protocol will first check to make sure that the patient's plasma was sampled at the correct
time. The acceptable time for adults (greater than 13 years) are from 40 to 55 minutes. For children (13
years of age and younger), acceptable are from 50 to 60 minutes.
If the time entered for plasma sampling is outside this range, the ERPF will not be calculated and the bladder
data will not be processed. You will, however, be able to review the reframed data and curves.
The PREVOID bladder dataset will be displayed in the upper left quadrant.
Outline bladder on prevoid image.

Use , , and to outline the bladder on the prevoid image. Press twice to
continue.
Outline crescent shaped background ROI below bladder

Use , , and to draw the prevoid bladder background ROI. For both the two
kidney and transplant patients, the prevoid bladder background ROI should be a narrow ring around the
END
lower portion of the bladder as illustrated. Press twice to continue.
Bladder background ROI's
TD4-3
The postvoid bladder image will then be displayed in the upper right quadrant, and you will be prompted to
draw the postvoid bladder and background ROI's. The postvoid bladder ROI should follow the outline of the
bladder, and the postvoid background ROI should be drawn as described for the prevoid background ROI.
The protocol will then calculate and display the results. At the end of processing the review menu will be
displayed:
Tauxe–Dubovsky Renal Review

1 Hippuran ERPF analysis
3 Reframed data and normalised curves
4 Exit
Enter menu choice and press SEND FORM
? :
Option 1 displays patient information, the global and differential ERPF values and kidney contributions,
and related information.
Option 2 displays patient information and the results of the bladder analysis.
Option 3 displays the reframed data and normalized, background subtracted curves.
All of these review modes are available any time after the data has been processed. Type in
`TXDUBPROCESS' to initiate the Tauxe-Dubovsky renal protocols and then select Òption 4 - Review
processed data'.
You can also access the review modes by typing in `TXDUBREVIEW' to initiate the Tauxe-Dubovsky review
protocol.
These review modes are further described in section 6.
TD4-4
5.1 ERPF Analysis
Complete processing will determine the global and differential effective renal plasma flow, fractional
hippuran excretion, and evaluate bladder function.
However, it is possible to determine just the effective renal plasma flow.
Select the appropriate patient and study.
To start the processing protocol type in the appropriate name:
TXDUBPROCESS
RETURN
and press .

2 ERPF analysis
3 Bladder analysis
4 Review process data
? :
SEND FORM
For ERPF analysis, enter a `2' and press to continue.
If the dataset REN FLWI is byte mode, you will be informed of this and exit the protocol. Convert this dataset
to word mode and rename it back to REN FLWI and then it can be processed.
The protocol will first check to make sure that the scratchpad exists and contains the patient and dosimetry
information. If the scratchpad does not exist, it will be created and you will be prompted to enter the patient
information as described in the acquisition protocol section. If the scratchpad exists but the patient
information is missing, you will be prompted to enter the patient information.
If the scratchpad exists and the patient information is there, but the dosimetry information is missing, you will
be prompted to enter the dosimetry information as described in the processing protocol section.
The dynamic dataset REN FLWI will be displayed in quadrant 1 and reframed into 1 minute per frame
images in quadrant 3. A 3 minute summed image will be created and displayed in quadrant 4.
The top half of the display will be cleared and the 1 minute reframed data will be displayed.
4. The ROI's will be duplicated on the reframed dataset in quadrant 3.
If the patient is a transplant patient you will see the following message:
Outline transplant kidney on summed image
TD5-1
Use , , and to outline the transplant kidney. Press twice to
continue.
Outline crescent shaped background ROI above transplant kidney

Use , , and to draw the transplant background ROI. Outline a narrow
ring around the upper portion of the kidney. Be careful to avoid the bladder as illustrated. Press
END
twice to continue.
If the patient is a two kidney patient you will, see the following message:
Outline right kidney on summed image

Use , , and to outline the right kidney. Press twice to continue.
Outline left kidney on summed image

Use , , and to outline the left kidney. Press twice to continue.
Outline crescent shaped background ROI to left of left kidney

Use , , and to draw the two kidney background ROI. The two kidney
END
background ROI should be a narrow ring around most of the left kidney as illustrated. Press
twice to continue.
Kidney background ROI's
The kidney and background curves will be generated in the upper left quadrant. These curves will be
background subtracted in quadrant 1. The background subtracted curves will be normalised first to counts
per minute vs minutes (quadrant 2) and then to counts vs minutes (quadrant 3).
TD5-2
The protocol will then calculate the results.
At the end of processing the review menu will be displayed:

4 Exit
Enter option & press SEND FORM key
? :
If complete processing was not done previously, the ERPF analysis and reframed data and normalised
review curves would be the only review modes that would be available.
5.2 Bladder Analysis
Complete processing will determine the global and differential effective renal plasma flow, fractional
hippuran excretion, and evaluate bladder function.
However, it is possible to just evaluate bladder function.
Select the appropriate patient and study.
TXDUBPROCESS
RETURN
and press .

2 ERPF analysis
3 Bladder analysis
Enter option & press SEND FORM key or ESCAPE to exit.
? :
SEND FORM
For bladder analysis, enter a `3' and press to continue.
The protocol will first check to make sure the scratchpad exists and contains the patient and dosimetry
information. If the scratchpad does not exist, it will be created and you will be prompted to enter the patient
information as described in the acquisition protocol section. If the scratchpad exists but the patient
information is missing, you will be prompted to enter the patient information.
If the scratchpad exists, and the patient information is there, but the dosimetry information is missing, you
will be prompted to enter the dosimetry information as described in the processing protocol section.
The display will be cleared to start the bladder analysis portion of the protocol.
Since some of the bladder calculations which are based on the ERPF, depend on the plasma sampling time,
the protocol will first check to make sure the patient's plasma was sampled at the correct time. The
TD5-3
acceptable times for adults are from 40 to 55 minutes. For children acceptable times are from 50 to 60
minutes.
If the time entered for plasma sampling is outside this range, you will see the message:
Can’t process bladder only if sampling time out of range
The bladder data will not be processed in this case.
The PREVOID bladder dataset will be displayed in the upper left quadrant.
Outline bladder on prevoid image.

Use , , and to outline the bladder on the prevoid image. Press twice to
continue.
Outline crescent shaped background ROI below bladder

Use , , and to draw the prevoid bladder background ROI. For both two-kidney
and transplant patients, the prevoid bladder background ROI should be a narrow ring around the lower
END
portion of the bladder as shown below. Press twice to continue.
Two kidney patient Transplant patient
Bladder background ROI's
The postvoid bladder image will then be displayed in the upper right quadrant, and you will be prompted to
draw the postvoid bladder and background ROI's. The postvoid bladder ROI should follow the outline of the
bladder, and the postvoid background ROI should be drawn as described for the prevoid background ROI.
The protocol will then calculate and display results. At the end of processing the review menu will be
displayed:

4 Exit
? :
If complete processing was not previously done, the bladder analysis review mode would be the only one
that could be reviewed.
TD5-4
6. REVIEW MODES
methods available to access the Schlegel review protocol.
1. The review protocol can be invoked from the TAUXE_DUBOVSKY protocol via menu
option `3'.
2. You can also access the review modes by typing in `TXDUBSCHLREVIEW' to initiate the
Schlegel review protocol.
3. Type in `TXDUBPROCESS' to initiate the Gates renal protocols and then select Òption 4
- Review processed data'.

4 Exit
Enter menu choice and press SEND FORM key.
? :
Option 1 displays patient information, the global and differential ERPF values and
kidney contributions, and related information.
Option 2 displays patient information and the results of the bladder analysis.
Option 3 displays the reframed data and background subtracted, normalised curves.
Hippuran ERPF Analysis
This option displays patient information, the global and differential ERPF values and kidney
contributions, and related information.
The 3 minute summed image with kidney and background ROI's superimposed will be
The background subtracted, normalized kidney curves will be displayed in quadrant 2. These
curves will be displayed as counts/sec versus seconds.
For a two kidney patient, a legend indicating which are the left and right kidneys will be
displayed below the curve axes.
Patient information will be displayed in the lower half of the display. The patient's height,
weight, and age will be displayed, and, if it was entered, so will the patient's blood pressure,
injected dose, sex, and state of hydration. The patient's body surface area, standard counts,
plasma counts, and time of blood sampling will be displayed in this same area.
The effective renal plasma flow (ERPF) report will be displayed below the patient information.
For a two kidney patient, this report includes the global and differential 1 to 2 minute counts,
per cent contributions, and ERPF's. The corrected ERPF expressed in ml/min will be displayed
below the ERPF value.
TD6-1
The corrected ERPF is the total ERPF times a standard body surface area of 1.73 divided by the
patient's body surface area.
For a transplant patient, this report includes the total and corrected ERPF's.

This review mode displays patient information and the results of the bladder analysis.
The prevoid image with bladder and background ROI's superimposed will be displayed in
quadrant 1.
The postvoid image with bladder and background ROI's superimposed will be displayed in
quadrant 2.
Patient information will be displayed in the lower half of the display. The patient's height,
weight, and age will be displayed, and, if it was entered, so will the patient's blood pressure,
injected dose, and state of hydration. The patient's body surface area and standard counts will
be displayed in this same area.
The urine sample data will be displayed below the patient information. These values include
the volume of urine collected in cubic centimetres, the urine sample counts, and the time in
minutes that the urine was collected.
The bladder analysis results will be displayed below the urine sample data. These results
include the prevoid bladder counts, the per cent expected excretion, the per cent total
excretion, the residual urine volume in cubic centimetres, the postvoid bladder counts, the
actual per cent voided, the excretion index, and the per cent dose in the bladder.
The prevoid and postvoid bladder counts displayed are the prevoid and postvoid background
subtracted bladder counts.
Reframed Data and Normalised Curves

This option displays the reframed data and background subtracted, normalized curves.
The reframed one minute per frame data will be displayed on the top half of the display.
The background subtracted, normalized kidney curves will be displayed on the lower half of
the display. These curves will be displayed as counts versus minutes. The peak filling time in
minutes for each kidney curve will be displayed above the curves.
For a two kidney patient, a legend indicating which are the left and right kidneys will be
displayed below the curve axes.
TD6-2
The Tauxe-Dubovsky renal protocol provides a method of estimating global effective renal
plasma flow (ERPF) based on a single blood sample. When combined with renal scintigraphy
using I-131-OIH, this method also provides differential ERPF's and kidney contributions,
fractional excretion, and evaluation of urinary bladder function.
This method has been validated on adults and children with both I-131 and I-123 hippuran,
(5). It can be used on two kidney and transplant patients.
Global ERPF
The global ERPF is estimated from the concentration of I-131-OIH remaining in the plasma
44 minutes after injection.
Regression equations based on the least squares best fit relate the 44 minute plasma
concentration with other estimates of ERPF, such as PAH and OIH clearances.
The formula for global ERPF is exponential:
-a(Vt - Vlag)
Y = Fmax [1 - e ]
where Fmax is a theoretical maximum ERPF value, a is the slope of curve, Vt represents the
theoretical volume of distribution of the injected OIH at sampling time, and Vlag is the x axis
intercept of the least squares line.
For a blood sample drawn at exactly 44 minutes, the formula for global ERPF is:
-0.008(V44 - 7.8)
ERPF (ml/min) = 1126.20 [1-e ]
counts of the injected dose (standard counts x 1000)

where V44 =
counts in 1 litre of plasma sampled at 44 minutes (plasma counts x 1000)
If the blood sample is drawn at a time other than 44 minutes, but within the range of 40 to 55
minutes, a different set of coefficients Fmax, a, and Vlag is used to minimize error. (1)
A separate set of coefficients based on a linear fit are used for children 13 years of age and
younger.
For children, the formula for global ERPF is :
Y = A + BX
where X represents the theoretical volume of distribution of the injected OIH at sampling time.
For a blood sample drawn at exactly 53 minutes, the formula for global ERPF is:
ERPF (ml/min) = 19.33 + 3.87 x X53
counts of the injected dose (standard counts x 1000)

where X53 =
counts in 1 liter of plasma sampled at 53 minutes (plasma counts x 1000)
If the blood sample is drawn at a time other than 53 minutes, but within the range of 50 to 60
minutes, a different set of coefficients A and B is used to minimize error. (2)
TD7-1
Differential ERPF's
Differential ERPF's are calculated by multiplying the global ERPF by the individual kidney
contributions, which are determined from the 1 to 2 minute background subtracted kidney
counts.
Left kidney contribution = x 100

Right kidney contribution = x 100
Left ERPF = (total ERPF x left kidney contribution)
Right ERPF = (total ERPF x right kidney contribution)
Corrected ERPF
The corrected ERPF is the total ERPF normalized to a standard body surface area of 1.73
square meters.
Corrected ERPF = total ERPF x 1.73

BSA
The DuBois formula is used to calculate the body surface area (BSA). (4)
.725 .425
BSA (sq m) = .007184 x (height ) x (weight )
where height is the patient height in centimetres and weight is the patient weight in kilograms.
Bladder Analysis
The fraction of the injected dose expected to be excreted in the urine at 35 minutes post
injection is calculated from the empirically derived formula:
% expected excretion = 79.3 [1 - e-(.004798 x ERPF)]
The actual percentage of the injected dose voided is determined from the measured voided
urine volume, and the activity in the injected dose (standard counts) and in a sample of urine
(urine counts).
Actual % voided = urine counts x voided urine(ml) x 100 (dilution) x 100

standard counts x 1000 (dilution)
TD7-2
The residual urine volume, the per cent of the dose remaining in the bladder, and the total per
cent of the dose excreted are calculated as follows:
voided urine (ml) x postvoid net bladder counts
Residual urine volume (ml) =
prevoid net bladder counts - postvoid net bladder counts
where the pre and postvoid net bladder counts are determined from bladder and background
ROI's drawn on the pre and postvoid images of the bladder.
Prevoid net prevoid prevoid
bladder counts = prevoid bladder counts - background counts x bladder area
prevoid background area
Postvoid net postvoid postvoid

bladder counts = postvoid bladder counts - background counts x bladder area
postvoid background area
x
% dose in bladder = actual % voided residual urine volume (ml)
voided urine (ml)
% total excretion = actual % voided + % dose in bladder
The excretory index (EI) is the ratio of the total per cent of the dose excreted to the per cent of
the dose expected to be excreted.
Excretory index = % total excretion

% expected excretion
TD7-3
TD7-4
8. REFERENCES
1. Tauxe WN, Dubovsky EV, Kidd T, et al.: New formulas for the calculation of effective renal plasma
flow. Eur J Nucl Med 7:551-554, 1982.
2. Tauxe WN and Dubovsky EV: Nuclear Medicine in Clinical Urology and Nephrology,
Appleton-Century-Crofts, 1985. Ch. 9, pp 157-167 and Ch 6, pp 83-87.
3. Dubovsky EV and Russell CD: Radionuclide evaluation of renal transplants. Seminars in Nuclear
Medicine XVIII, 3:181-198, 1988.
4. DuBois D and DuBois EF: Clin. Cal. 10, Arch. Int. Med.,17,863,1916.
5. Russel CD and Dubovsky EV: Uncontrolled variables in the measurement of renal function. J Nucl
Med 27:1644 (letter to the editor), 1986.
TD8-1
TD8-2
DREF FLOW REN FLWI reframed into 1 minute per frame images
DSUM3 summed 0-3 minute static image
DTKROI transplant kidney ROI
DTKROI.C1 transplant kidney curve
DTBSCRV background subtracted transplant kidney curve
DTBSCPM background subtracted transplant kidney curve in
counts/minute vs minutes
DTBSCVM background subtracted transplant kidney curve in
counts vs minutes
DRKROI right kidney ROI
DRKROI.C1 right kidney curve
DRBSCRV background subtracted right kidney curve
DRBSCPM background subtracted right kidney curve in
DRBSCVM background subtracted right kidney curve in
counts vs minutes
DLKROI left kidney ROI
DLKROI.C1 left kidney curve
DLBSCRV background subtracted left kidney curve
DLBSCPM background subtracted left kidney curve in
DLBSCVM background subtracted left kidney curve in
counts vs minutes
DBROI background ROI
DBROI.C1 background curve
DPREROI1 prevoid bladder ROI
DPREROI2 prevoid background ROI
DPOSTROI1 postvoid bladder ROI
DPOSTROI2 postvoid background ROI
TXDUB DATA scratchpad
TDA - 1
TDA - 2
This is a description of the scratchpad registers used by the Tauxe-Dubovsky
protocols. These registers are saved as the scratchpad dataset TXDUB DATA.
@S3 patient information entered
@S4 count information entered
@S7 curves and reframe processing completion flag
@S8 ERPF processing completion flag
@S9 bladder processing completion flag
@S10 patient height (cm)
@S11 patient weight (kg)
@S12 patient age in years
@S13 transplant (1) or two kidney (2) patient
@S16 hippuran dose (mCi)
@S17 state of hydration (1=hydrated, 2 = not)
@S18 patient sex (1 = male, 2 = female)
@S20 standard counts
@S21 urine volume (ml)
@S22 time in minutes patient voided
@S23 urine counts
@S24 time in minutes blood sampled
@S25 plasma counts
@S30 right background subtracted 1-2 minute counts
@S31 left background subtracted 1-2 minute counts
@S32 total background subtracted 1-2 minute counts
@S37 body surface area - BSA - DuBois formula
@S40 reciprocal plasma concentration
@S45 time to peak for right or transplant background subtracted curve
@S46 time to peak for left background subtracted curve
@S51 right uptake
@S52 left uptake
@S53 total ERPF
@S54 right ERPF
@S55 left ERPF
@S57 right kidney % contribution
@S58 left kidney % contribution
@S59 correction factor for ERPF based on BSA
@S60 ERPF corrected for BSA
TDB-1
@S70 area of prevoid ROI
@S71 counts in prevoid ROI
@S72 area of prevoid background ROI
@S73 counts in prevoid background ROI
@S74 total prevoid counts (prevoid ROI counts minus normalized
background counts
@S75 area of postvoid ROI
@S76 counts in postvoid ROI
@S77 area of postvoid background ROI
@S78 counts in postvoid background ROI
@S79 total postvoid counts (postvoid ROI counts minus normalized
background counts)
@S80 % expected excretion
@S81 residual urine volume (cc)
@S82 actual % voided
@S83 % dose in bladder
@S84 % total excretion
@S85 excretion index (EI)
@S251 user response to processing menu
@S252 user response to review menu
TDB-2
APPENDIXHEIGHT
C - HEIGHT AND WEIGHT CONVERSION WEIGHT
TABLES
152.4 5 0 100 45.4
153.7 5 0 12 101 45.9
155 5 1 102 46.3
156.2 5 1 12 103 46.8
157.5 5 2 104 47.2
158.8 5 2 12 105 47.7
160 5 3 106 48.1
161.3 5 3 12 107 48.6
162.3 5 4 108 49.0
163.8 5 4 12 109 49.5
110 49.9
165.1 5 5 111 50.4
166.4 5 5 12 112 50.8
168 5 6 113 51.3
168.9 5 6 12 114 51.8
170.2 5 7 115 52.2
171.5 5 7 12 116 52.7
172.7 5 8 117 53.1
174.0 5 8 12 118 53.6
175.3 5 9 119 54.0
176.5 5 9 12 120 54.5
177.8 5 10 121 54.9
179.1 5 10 12 122 55.4
5 11 123 55.8
180.3 124 56.3
181.6 5 11 12 125 56.8
182.9 6 0 126 57.2
184.2 6 0 12 127 57.7
185.4 6 1 128 58.1
186.7 6 1 12 129 58.6
188.0 6 2 130 59.0
189.2 6 2 12 131 59.5
190.5 6 3 132 59.9
191.8 6 3 12 133 60.4
193.0 6 4 134 60.8
194.3 6 4 12 135 61.3
195.6 136 61.7
6 5 137 62.2
196.9 6 5 12 138 62.7
198.1 6 6 139 63.1
TDC–1
WEIGHT WEIGHT

140 63.6 180 81.7
141 64.0 181 82.2
142 64.5 182 82.6
143 64.9 183 83.1
144 65.4 184 83.5
145 65.8 185 84.0
146 66.3 186 84.4
147 66.7 187 84.9
148 67.2 188 85.3
149 67.6 189 85.8
150 68.1 190 86.3
151 68.6 191 86.7
152 69.0 192 87.2
153 69.5 193 87.6
154 69.9 194 88.1
155 70.4 195 88.5
156 70.8 196 89.0
157 71.3 197 89.4
158 71.7 198 89.9
159 72.2 199 90.3
160 72.6 200 90.8
161 73.1
162 73.5
163 74.0
164 74.5
165 74.9
166 75.4
167 75.8
171 77.6
173 78.5 1 pound = 0.454 kilogram
174 79.0
175 79.5
176 79.9
177 80.4
178 80.8
179 81.3
TDC–2
Patient name
Hippuran dose injected (mCi)
Time of injection
Time post-injection blood sampled (minutes)
Time post-injection patient voided (minutes)
First plasma well counter tube reading
Second plasma well counter tube reading
Average plasma well counter reading (PLASMA COUNTS)
First urine well counter tube reading
Second urine well counter tube reading
Average urine well counter tube reading (URINE COUNTS)
First standard well counter tube reading
second standard well counter tube reading
Average standard well counter tube reading (STANDARD COUNTS)
Dose calibrator reading of syringe before injection
Dose calibrator reading of syringe after injection
Amount of dose left in syringe
Percent of dose not injected
(i.e dose left in syringe/dose before injection)
PLEASE REFER TO SECTION 3 OF THE TAUXE-DUBOVSKY MANUAL FOR MORE INFORMATION
TDD–1
TDD–2

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SCHLEGEL RENAL PROTOCOL

Richard Prima, R.T. (ASRT)

General Electric Medical Systems

August 18th, 1989

1. PATIENT PREPARATION AND SETUP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 - 1

2. HOW TO USE THE SYRINGE HOLDER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 - 1

4. HOW TO DETERMINE URINE VOLUME AND COUNTS . . . . . . . . . . . . . . . . 4 - 1

I131 Hippuran Individual Kidney Contributions . . . . . . . . . . . . . . . . . . . . . . . . . 8 - 2

Expected Normal ERPF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 - 2

I131 Hippuran Returns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 - 3

Total and Differential GFR's . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 - 3

Normal Total GFR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 - 4

Tc-99m-DTPA Individual Kidney Contributions . . . . . . . . . . . . . . . . . . . . . . . . 8 - 4

Use I131 hippuran for the hippuran acquisitions.

Dr. Schlegel recommends the following doses based on age:

Use a 3 cubic centimetre syringe.

butterfly tubing, flush with 2 or 3 cubic centimetres of saline.

calculations and it needs to be accurate.

Any infiltration of the dose would make the results inaccurate.

Syringe flange must

will be 18 centimetres from the bottom of the syringe holder.

The following menu will then be displayed:

SCHLEGEL RENAL PROTOCOL

Please enter selection followed by <SEND FORM>

3 only patient selection is allowed.

protocol, SCHLPROCESS. Selecting option 3 calls the review protocol, SCHLREVIEW.

following screen is displayed:

Maxxus Detector Selection Menu

Please select detector for acquisition

study which acquisitions need to be performed.

be stored under the same study `SCHLEGEL RENAL'.

renal plasma flows (ERPF's).

Tc-99m-DTPA analysis by itself will determine individual kidney contributions.

the Tc-99m-DTPA must be acquired before the hippuran data.

1. Static dataset - PRE SYRI

2. Dynamic dataset - REN FLWI

The resolution can be changed to 128 x 128.

mode and rename it to REN FLWI before it can be processed.

ORSP––––––––––––––––––––––––––––––––––––––––SCHLEGEL RENAL PROTOCOL

(automatic or manual). This information is required by the processing protocol.

formulas of Tonnesen, et al.

Have the transplant kidney centered in the field of view.

start the dynamic acquisition.

dataset. The name of the dataset is SCHL DATA.

Hippuran 15 minute static acquisition

The acquisition protocol will then set up the following acquisition:

1. Static dataset - H15MIN

changed to 128 x 128.

This image should be acquired 15 minutes post injection.

Have the transplant kidney centered in the field of view.

dataset. The name of the dataset is SCHL DATA.

Hippuran 25 Minute Static Acquisition

The acquisition protocol will then set up the following acquisition:

1. Static dataset - H25MIN

changed to 128 x 128.

This image should be acquired 25 minutes post injection.

Have the transplant kidney centered in the field of view.

dataset. The name of the dataset is SCHL DATA.