Childhood diarrhea/ diarrhoea in childhood

Childhood diarrhea is one of the major gastrointestinal conditions affecting toddlers. Childhood diarrhea is defined as frequent passage of loose stools or, more accurately, passage of an increased volume of stool water. A stool volume of more than 200 ml/m2/day indicates diarrhoea, as does a stool weight of more than 150–200 g watery stool/ m2/day. But precise measurements are difficult in children. So more convenient definitions are as follows;

infancy and childhood diarrhea is defined as an increase in stool frequency associated with a change to loose or watery stools. It must be remembered that normal breast-fed infants may pass frequent loose stools. Diarrhoea in a breast-fed infant is defined as a departure from the normal stool pattern with increased volume and frequency.

Types of childhood diarrhea

acute diarrhea; less than weeks’ duration.
chronic diarrhea; more than 2 weeks’ duration

causes for childhood diarrhea

Medical causes for childhood diarrhea

1. Infections –gastroenteritis, meningitis, septicaemia and urinary tract infection may be associated with gastrointestinal symptoms
2. Coeliac disease – diarrhoea and vomiting may be prominent; history of prolonged ill health; must have gluten in diet for symptoms
3. Cows’ milk protein and other food intolerances – essential to take careful history; short-term dietary elimination may be necessary to make the diagnosis ± small intestinal biopsy
4. Haemolytic–uraemic syndrome – vomiting and diarrhoea may be present; raised blood urea and characteristic changes in blood fi lm suggest the diagnosis

Surgical causes for childhood diarrhea

1. Pyloric stenosis – age at onset 2–8 weeks; projectile vomiting and constipation (not diarrhoea); pyloric tumour on physical examination and test feed
2. Intussusception – colicky pain; sausage-shaped mass in abdomen; ‘redcurrant jelly’ stools; atypical or minimal physical signs in many infants; vigilance required
3. Acute appendicitis – seldom occurs in infancy; must consider in older children
4. Hirschsprung’s disease – presents with aggressive form of colitis if not diagnosed in neonatal period; careful history reveals constipation from birth; diagnosis suggested by barium enema and anorectal manometry, confi rmed by rectal biopsy

Liver diseases and SGOT/SGPT test pattern

Viral hepatitis and SGOT/SGPT test

Pattern of the SGOT/SGPT test pattern or the degree of SGOT/SGPT enzyme elevation in the blood is a good way of diagnosing different liver diseases. Different types of liver diseases give rise to different level of SGOT/SGPT enzyme test value. But these enzyme changes are not diagnostic but help in the process of diagnosis.

In most acute hepatocellular disorders, the SGPT is higher than or equal to the SGOT. An SGOT:SGPT ratio>2:1 is suggestive while a ratio >3:1 is highly suggestive of alcoholic liver disease. The AST in alcoholic liver disease is rarely >300 U/L and the SGPT is often normal. A low level of SGPT in the serum is due to an alcohol-induced deficiency of pyridoxal phosphate. The aminotransferases are usually not greatly elevated in obstructive jaundice. One notable exception occurs during the acute phase of biliary obstruction caused by the passage of a gallstone into the common bile duct. In this setting, the aminotransferases can briefly be in the 1000 to 2000 U/L range. However, aminotransferase levels decrease quickly, and the liver function tests rapidly evolve into one typical of cholestasis.

Liver disease	SGOT/SGPT test pattern
Gilbert’s syndrome	normal
Liver diseases with hemolysis	Normal (usually)
Viral hepatitis	>500 IU SGPT>SGOT
Drug hepatitis	>500 IU SGPT>SGOT
Acute hepatocellular Necrosis (heart failure)	>500 IU SGPT>SGOT
Chronic hepatocellular disorders	Elevated, but usually >300 IU
Alcoholic hepatitis	AST:ALT >2
Cirrhosis	AST:ALT >2
Obstructive jaundice	Normal to moderate elevation Rarely >500 IU
Infiltrative diseases (tumor, granulomata)	Normal to slight elevation
Intra- and extra hepatic cholestasis	Normal to moderate elevation Rarely >500 IU

G6PD enzyme test

3-D View of G6PD enzyme
G6PD enzyme test is one of the important enzyme tests in diagnosis of the exact cause of hemolytic anemia. G6PD enzyme test is the definitive diagnosis investigation for G6PD deficiency hemolytic anemia. G6PD stands for Glucose-6-phosphate dehydrogenase. G6PD enzyme converts glucose-6-phosphate into 6-phosphoglucono-δ-lactone and is the rate-limiting enzyme of the pentose phosphate pathway.

G6PD enzyme deficiency is one of the major causes of hemolytic anemia worldwide. Hemolytic anemia due to G6PD enzyme problem could be due to the absence of the G6PD enzyme or mutations of the G6PD enzyme. The degree of G6PD deficiency or mutation is variable. There is a wide range of deficiencies and mutations.


Before doing G6PD enzyme test there are several tests to be done such as complete blood count, liver enzymes and Coomb’s test. These tests are done to rule out other cause for hemolytic anemia.

There are two tests to detect G6PD enzymes level. The Beutler fluorescent spot test and the Motulsky dye-decolouration test are the two G6PD enzyme test. Second one is the oldest test and it is not done now a days. The Beutler fluorescent spot test is very quick. It detects the products (NADPH) of G6PD enzyme catalyzing reaction. Ultraviolet (UV) is employed to detect NADPH. Thistest can not be done when there is active hemolysis going on.

Liver diseases & SGOT/SGPT test

SGOT and SGPT enzymes are primarily found in liver cells. Therefore liver diseases and SGOT/SGPT test has a close association. SGOT enzyme is basically a cytosolic enzyme (mainly present in the cytosol of the liver cells) whereas SGPT enzyme is found in mitochondria of liver cells. Because of these reasons High SGOT/SGPT test values usually indicated liver dysfunction.

Since SGOT enzyme is a cytosolic enzyme, mild to moderate liver damage result elevation of SGOT enzyme level in the blood than that of SGPT enzyme. To have a high SGPT enzyme level in the blood, liver damage should be marked. Therefore SGOT/SGPT test values depend on the degree of liver damage.

Hepatitis (viral or non-viral), alcoholic liver disease, cirrhosis, fatty liver diseases, eclampsia and HELLP syndrome are the common liver condition which result in high SGOT/SGPT test value.

Rarely viral hepatitis result in serious liver damage therefore viral hepatitis usually gives rise to high SGOT and normal SGPT level. Even though this is the case with Hepatitis A infection, Hepatitis B can result in severe liver damage thus result in markedly elevated SGOT/SGPT test value.

Alcoholic liver disease, cirrhosis and fatty liver disease result in moderately increased SGOT/SGPT test value. Eclampsia and HELLP are pregnancy associated liver conditions and those can result severe liver damage.

Enzyme	normal	Moderately high	high
SGOT	0-42	42-200	>200
SGPT	0-48	48-150	>150

CSF analysis test

CSF stands for cerebro-spinal fluid

CSF analysis or test is widely used to diagnose the conditions affecting central nervous system. Components of CSF analysis or test are color of the CSF, pressure of the CSF, specific gravity of the CSF, cells (white blood cells, lymphocytes, red blood cells) count of the CSF and organism found in the CSF

Conditions diagnosed by CSF analysis or test

Infections (bacterial, mycobacterium, viral and fungal) of the central nervous system, bleeding in to the CSF (sub arachnoid hemorrhage), hydrocephalus and leukamias are the common conditions diagnosed by using CSF analysis or test.

Clinical importance of CSF analysis or test

1. diagnosis of conditions affecting central nervous system
2. monitoring of response to treatment
3. monitoring of progression of leukamias

Diagnosis of CNS infections with CSF analysis or test

causes	appearance	neutrophils	lymphocytes	protein	glucose
Bacterial meningitis	Yellowish turbid	Very high	High/ normal	High/normal	decrease
Viral meningitis	Clear	High/normal	Very high	Very high	normal
Tuberculous meningitis	Yellowish viscous	High/normal	Very high	High/normal	decrease
Fungal meningitis	Yellowish viscous	High/normal	Very high	High/normal	Normal/ decrease

ALT enzyme

ALT enzyme is found in cytosol of the liver cells. ALT stands for Alanine transaminase. ALT enzyme is also found in heart (cardiac) muscle cells and skeletal muscles cells as well. Therefore damage to the liver cells, cardiac muscle cells and skeletal muscle cells can give rise to increased level of ALT enzyme in the blood.

ALT enzyme catalyses the following reaction.



ALTenzyme level is one component of the liver function test. As it is a cytosolic enzyme, milder damage to liver can give rise to elevated level of ALT enzyme in the blood. It is not the case with AST enzyme.

viral hepatitis, congestive heart failure, liver damage, biliary duct problems, infectious mononucleosis and myopathy are some of the diseases which result in high ALT enzyme level in the blood. Therefore, to detect the exact cause of elevated ALT enzyme in blood, other investigations should be done.

Normal ALT enzyme level is ranging from 0-42 U/L

AST/ALT blood test

SGPT enzyme

SGPT enzyme is found in cytosol of the liver cells. SGPT stands for serum glutamic pyruvic transaminase. SGPT enzyme is also found in heart (cardiac) muscle cells and skeletal muscles cells as well. Therefore damage to the liver cells, cardiac muscle cells and skeletal muscle cells can give rise to increased level of SGPT enzyme in the blood.

SGPT enzyme catalyses the following reaction.



SGPT enzyme level is one component of the liver function test. As it is a cytosolic enzyme, milder damage to liver can give rise to elevated level of SGPT enzyme in the blood. It is not the case with SGOT enzyme.

viral hepatitis, congestive heart failure, liver damage, biliary duct problems, infectious mononucleosis and myopathy are some of the diseases which result in high SGPT enzyme level in the blood. Therefore, to detect the exact cause of elevated SGPT enzyme in blood, other investigations should be done.

Normal SGPT enzyme level is ranging from 0-42 U/L

SGOT/SGPT blood test

AST enzyme

AST enzyme is an enzyme which is mainly found in liver cell. AST is the shorten form for Aspartate transaminase. Red blood cells, cardiac or heart muscles, skeletal muscles, kidney and brain are the other tissues where AST enzyme found. AST enzyme is one of the most important enzymes in clinical practice. Main function of AST enzyme is to catalyze the conversion of aspartate and alpha-ketoglutarate to oxaloacetate and glutamate, and vice-versa.

AST enzyme is found in two forms or two isoenzymes. AST1 enzyme is the form which is mainly found in cytosol of red blood cells and heart muscles cells. AST2 enzyme is the form which is found in mitochondria of liver cells therefore AST2 enzyme is more important in liver diseases.

Since AST enzyme is found in mitochondria of liver cells, sever liver damages can give rise to elevated AST enzyme level. Usually mild to moderate liver damage do not give rise to significant elevation of AST enzyme. As it is present in red blood cells, hemolysis can result in elevated AST enzyme level in the blood. This enzyme is also found in cardiac or heart muscle cells, so it may be important in ischemic heart disease diagnosis as well.

Normal AST enzyme level in blood is ranging from 0 to 48 U/L.

AST/ALT blood test

SGOT enzyme

SGOT enzyme is an enzyme which is mainly found in liver cell. SGOT is the shorten form for serum glutamic oxaloacetic transaminase. Red blood cells, cardiac or heart muscles, skeletal muscles, kidney and brain are the other tissues where SGOT enzyme found. SGOT enzyme is one of the most important enzymes in clinical practice. Main function of SGOT enzyme is to catalyze the conversion of aspartate and alpha-ketoglutarate to oxaloacetate and glutamate, and vice-versa.

SGOT enzyme is found in two forms or two isoenzymes. SGOT1 enzyme is the form which is mainly found in cytosol of red blood cells and heart muscles cells. SGOT2 enzyme is the form which is found in mitochondria of liver cells therefore SGOT2 enzyme is more important in liver diseases.

Since SGOT enzyme is found in mitochondria of liver cells, sever liver damages can give rise to elevated SGOT enzyme level. Usually mild to moderate liver damage do not give rise to significant elevation of SGOT enzyme. As it is present in red blood cells, hemolysis can result in elevated SGOT enzyme level in the blood. This enzyme is also found in cardiac or heart muscle cells, so it may be important in ischemic heart disease diagnosis as well.

Normal SGOT enzyme level in blood is ranging from 0 to 48 U/L.

SGOT/SGPT blood test

AST/ALT blood test

AST/ALT blood test is a one of the liver function tests. Primary use of AST/ALT blood test is to assess the state of the liver function. AST and ALT are two enzymes found in the liver.

AST; Aspartate transaminase serum glutamic oxaloacetic transaminase (SGOT)
ALT; Alanine transaminase serum glutamic pyruvic transaminase (SGPT)

AST is found in the cytosol of the liver cell where as ALT is found in the mitochondria. This is why mild and moderate liver damage gives high AST and normal ALT (usually) value and sever liver damage gives high AST and ALT test value. Other tissues where AST enzyme found are red blood cells, cardiac muscle, skeletal muscle, kidney and brain tissue therefore damage to these result in high AST level in the blood. ALT is also found in cardiac and skeletal muscles therefore damage to these tissues can result in elevated AST/ALT test value. If AST/ALT blood test is ordered by your doctor, you may be suffering from some kind of liver disease such as hepatitis (viral or alcoholic liver disease). Normal and high AST/ALT blood test values and their possible causes are given below.

Normal AST/ALT test value;

1. AST; Normal Adult Range: 0 - 48 U/L
2. ALT; Normal Adult Range: 0 - 42 U/L

High AST/ALT blood test values found in following conditions;

1. viral hepatitis
2. alcoholic liver diseases
3. non alcoholic liver disease
4. liver cell necrosis

SGOT/SGPT blood test

SGOT/SGPT blood test is a one of the liver function tests. Primary use of SGOT/SGPT blood test is to assess the state of the liver function. SGOT (AST) and SGPT(ALT) are two enzymes found in the liver.

SGOT; serum glutamic oxaloacetic transaminase: Aspartate transaminase (AST)
SGPT; serum glutamic pyruvic transaminase: Alanine transaminase (ALT)

SGOT is found in the cytosol of the liver cell whereas SGPT is found in the mitochondria. This is why mild and moderate liver damage gives high SGOT and normal SGPT (usually) value and sever liver damage gives high SGOT /SGPT blood test value. Other tissues where SGOT enzyme found are red blood cells, cardiac muscle, skeletal muscle, kidney and brain tissue therefore damage to these tissues result in high SGOT level in the blood. SGPT is also found in cardiac and skeletal muscles therefore damage to these tissues can result in elevated SGOT/SGPT blood test value. If SGOT/SGPT blood test is ordered by your doctor, you may be suffering from some kind of liver disease such as hepatitis (viral or alcoholic). Normal and high SGOT/SGPT test values and their possible causes are given below.

Normal SGOT/SGPT test value;

1. SGOT; Normal Adult Range: 0 - 48 U/L
2. SGPT; Normal Adult Range: 0 - 42 U/L

High SGOT/SGPT test values found in following conditions;

1. viral hepatitis
2. alcoholic liver diseases
3. non alcoholic liver disease
4. liver cell necrosis

READ MORE;

1. ALT ENZYME
2. AST ENZYME
3. SGPT ENZYME
4. SGOT ENZYME
5. AST/ALT BLOOD TEST
6. SGOT/SGPT ENZYME TEST
7. LIVER DISEASE AND SGOT/SGPT TEST
8. GILBERT'S SYNDROME AND SGOT/SGPT TEST

CMV infection in kidney transplant

CMV in kidney transplant

CMV in kidney transplant is one of the major transplant problems. CMV stands for cytomegalovirus. CMV infection in kidney transplant increases with the degree of Immunosuppression. As most of the recipients are on immunosuppressant, CMV infection is a considerable infection. So Immunosuppression increases the susceptibility of kidney transplant recipients to infection. CMV or cytomegalovirus is one of the commonest viral infections among normal population,so it is implicated in kidney transplant as well. It is a standard practice that all the kidney recipients and kidney donors are tested for previous exposure to CMV infection. If the kidney recipient is previously exposed to CMV infection, there will be some protection after kidney transplant. But, still that person is at risk of CMV infection due to the immunosuppressant therapy. If the kidney donor is previously exposed to CMV and the recipient is not exposed, the kidney recipient will be at risk of CMV infection after kidney transplant.

Sing and symptoms of CMV in kidney transplant

Features depend on the capability of the immune system. Infection typically presents with malaise, high spiking fever, neutropenia and abnormal liver function tests, or with localized disease in an individual organ (e.g. kidney, liver, lungs). Immunocompromised individuals are at high risk of CMV following kidney transplant.

Treatment and prevention of CMV in kidney transplant

Prevention of the CMV in kidney transplant is the best treatment available therefore all the kidney recipient and kidney donors will undergo antibody test to detect the previous infection with CMV. If both are infected, the risk will be low. If kidney recipient is not infected, he/she will be at higher risk. Antiviral therapy (e.g. ganciclovir) may be used prophylactically to reduce the risk of CMV disease and also to treat patients in whom the disease has developed.

High levels of LDL (bad) cholesterol

High LDL (bad) cholesterol is a risk factor for cardiovascular disease (IHD, MI) and for cerebrovascular diseases. LDL stands for Low Density Lipoprotein. Low-density lipoprotein (LDL) is a type of lipoprotein that transports cholesterol and triglycerides from the liver to peripheral tissues. LDL cholesterol is a part of blood cholesterol test. High level of LDL cholesterol associated with cardiovascular and cerebrovascular diseases therefore it is also known as bad cholesterol.LDL (bad) Cholesterol transports cholesterol from liver to other sites. This transportation process help to retain some cholesterol in the arteries therby increase the risk of atheroma formation. So high level of LDL (bad) cholesterol is associated with atheroma formation.

Normal and high risk values of LDL (bad) cholesterol

Mg/dL	mmol/L	comments
<100	<2.6	Optimal LDL cholesterol
101-129	2.6-3.3	Near optimal LDL level
130-159	3.3-4.1	Borderline high LDL level
160-189	4.1-4.9	High LDL level
>190	>4.9	Very high LDL level

Diseases associated with High levels of LDL (bad) cholesterol

1. Atherosclerosis
2. Heart attack
3. Stroke
4. Peripheral vascular diseases

Treatment for High levels of LDL (bad) cholesterol

• drugs used to treat High levels of LDL (bad) cholesterol: statin, clofibrate, niacin, tocotrienols.
• dietary advices for levels of LDL (bad) cholesterol; reduce consumption of fat, starch and sugar, increase the consumption of vitamin like C,E and A.

Lifestyle modification for levels of LDL (bad) cholesterolstop

• smoking
• avoid alcohol
• regular exercise
• good dietary hobbits
• regular medical checkup

Blood tests for crohn’s disease

There are several blood tests available for crohn’s disease to be diagnosed. Crohn’s disease is an inflammatory bowel disease which mainly affects the large intestine. Blood loss and vitamin B12 deficiency are common with crohn’s disease so it can lead to anemia. A full blood count or complete blood count is done to detect anemia. To recognize the severity of the inflammation associated with crohn’s disease Erythrocyte sedimentation rate, or ESR, and C-reactive protein can be done. Testing for anti-Saccharomyces cerevisiae antibodies (ASCA) and anti-neutrophil cytoplasmic antibodies (ANCA) has been evaluated to identify inflammatory diseases of the intestine and to differentiate Crohn's disease from ulcerative colitis. Following are the blood tests for crohn’s disease

1. A full blood count
2. Erythrocyte sedimentation rate, or ESR
3. C-reactive protein
4. anti-Saccharomyces cerevisiae antibodies (ASCA)
5. anti-neutrophil cytoplasmic antibodies (ANCA)

Blood cholesterol test/cholesterol testing

Blood cholesterol test or cholesterol testing is an investigation which is done to detect the cholesterol level in the blood. Blood cholesterol test or cholesterol testing is one of the most important tests for patients with high blood pressure, heart attack and diabetes. Blood cholesterol test is an essential investigation in regular medical checkup.

When to do blood cholesterol test or cholesterol testing

Usually this is a routing investigation of regular medical check-up. It is recommended that all the men and women above 20 years and test should be done in every 5 years time. This test is done after 14 hours of fasting.

Components of blood cholesterol test or cholesterol testing

1. LDL cholesterol
2. VLDL cholesterol
3. HDL cholesterol
4. total cholesterol
5. triglycerides
6. HDL/LDL ratio

Blood cholesterol test or cholesterol testing values.

type (mg/dl)	optimal	normal	borderline	high	Very high
LDL cholesterol	<100	100-129	130-159	160-189	>190
HDL cholesterol	<40	40-60	60-75	>75
Total cholesterol	<200		200-239		>240
Triglycerides	<150	150-199	200-499	>500

High blood cholesterol test or cholesterol testing (hypercholesterolemia)

Blood cholesterol test is considered as high when LDL cholesterol is above 130 mg/dl and HDL cholesterol is below 40 mg/dl. High blood cholesterol test is associated with high risk of cardiovascular diseases like heart attack. But, up to 150 mg/dl of LDL cholesterol is considered as normal if there are no other risk factors such as smoking, high blood pressure.

Urine culture test and sensitivity

Urine culture test is performed to detect the organisms causing urinary tract infection. Urine culture test is one of the popular urinary investigations.

Samples for urine culture test

1. Urine collected via urethra
2. Catheter sample
3. Supra-pubic aspiration

Urine for culture is usually collected via urethra. The distal 1/3 of the urethra has a normal flora which results in low level of contamination (100/ml) of urine during collection.

Instructions to patients regarding collection of a sample of urine for urine culture test.

About 10 ml of urine is collected into a chemically clean container.
• early morning urine – collected from the first void
• Double voided urine – collected about 1-2 hours after the first void
• random urine – collected at any time of day
• spot urine - a sample of urine collected at the same time as blood.

Timed urine

All the urine passed within a stipulated time period is collected. The commonest is a 24-hour collection of urine. A prior appointment may be needed from the laboratory.

Steps

1. Obtain a container from the laboratory to collect urine. The container will have a preservative; do not wash it off. If a preservative is not recommended, the sample needs to be refrigerated during the collection period.
2. Empty the bladder fully, discarding the urine – (usually at about 7 am) and note the time.
3. Collect all the urine passed until the same time the next day (i.e 7 am on following day) into the container issued by the laboratory. (The patient may use a separate clean bowl to collect and transfer the urine sample in to the given container.)
4. The final sample is passed at 7 am (in above example) and is collected into the container.
5. Label the container (name, age sex, name of test, start time, finish time, date)
6. Hand over the sample to the laboratory without delay.
7. If a clearance test has been ordered (eg. Creatinine clearance), a blood sample too will be collected on submitting the urine sample.

Results of urine culture test

The presence of a single type of bacteria growing at high colony counts (greater than 10,000 colony forming units (CFU)/ml) is considered a positive urine culture. A culture that is reported as "no growth in 24 or 48 hours" or "less than 10,000 CFU/ml" usually indicates that there is no infection. If the symptoms persist, however, the culture may be repeated to look for the presence of bacteria at lower colony counts (less than 10,000 CFU/ml) or other microorganisms that may cause these symptoms. The presence of white blood cells and low numbers of microorganisms in a symptomatic patient is a condition known as acute urethral syndrome.

Renal (kidney) biopsy

Renal biopsy is an investigation done to detect structural disorders of the kidney. Renal biopsy provides a sample of kidney tissue that can be examined to detect information that helps clinical management. The procedure is undertaken in specialized centers by trained or supervised medical practitioners.

Indications for renal biopsy

1. renal failure
2. proteinuria (protein found in urine)
3. hematuria (blood found in urine)

Information detected by doing renal biopsy
Pathologists can provide two important pieces of information.

• The diagnosis guides further investigations and clinical management, and suggests the likely course and outcome of the illness.
• An assessment of the degree of chronic, irreversible damage indicates the time that the kidney is likely to survive before its function becomes so poor that renal replacement therapy is required.

Nephrotic syndrome and renal biopsy

In many parts of the world, nephrotic syndrome is the main or only indication for biopsy. Patients with the syndrome have heavy proteinuria with oedema and hypoalbuminaemia. A glomerular disorder is always present, because glomeruli are the only structures that can leak sufficient albumin into the urine to produce the syndrome. Biopsy is undertaken in most adults but seldom in children; several possible findings in adults affect clinical management, but most children can be managed successfully without confirmation of the glomerular disorder.

Acute renal failure (ARF) and renal biopsy
Few patients with ARF undergo renal biopsy. The cause of ARF is usually evident clinically (e.g. under-perfusion of the kidneys as a result of septic shock, severe haemorrhage or myocardial infarction) and biopsy is needed only when there is no obvious explanation.

Chronic renal failure (CRF) and renal biopsy

In CRF, there are fewer nephrons than normal either because the kidney has not developed normally, or as a result of irreversible nephron loss. Unlike ARF, which may resolve depending on the cause, CRF does not improve; beyond a certain degree of impairment, it progresses inevitably until renal replacement therapy is required or death occurs. This is partly because the surviving nephrons become larger and increase their function to compensate for lost nephrons, but these changes lead to damage, particularly in the glomeruli, and cause further nephron loss. CRF has many possible causes. Biopsy is used only when the cause is not obvious from other investigations, and is not per- are IgA nephropathy (Figure 3) and thin glomerular basement membrane disease. In children, the most common findings are these two conditions and hereditary nephropathy of the Alport type. If IgA nephropathy is excluded, the remaining conditions are among the few that require electron microscopy for diagnosis.

Renal allografts (kidney transplant) and renal biopsy
Biopsy is used in recipients of an allograft to determine whether an immune response against the transplanted kidney (rejection) is present. Acute rejection usually occurs soon after transplantation and often takes the form of acute cellular rejection. Acute vascular rejection is less common and more difficult to treat. Many grafts develop slow narrowing of the arteries leading to ischemia, loss of tubules and decline in function; this is traditionally termed ‘chronic vascular rejection’.

Investigations for heart failure

There are several investigations for heart failure. Those investigations of heart failure help to identify the cause of the heart failure, degree of heart failure and prognosis of the heart failure.

Chest radiography for heart failure

Chest X-ray is done to exclude the lung causes of symptoms (heart failure). If the patient is well treated chest X-ray should be clear. Otherwise it will show evidence of heart failure such as kerley B line bat wing sing. Up to 50% of patients with chronic heart failure have a normal-sized heart on chest radiography, which is not a useful test for excluding left ventricular (LV) dysfunction.

ECG in heart failure:

12-lead ECG is almost never normal in heart failure. However, an abnormal ECG does not help make the diagnosis. The ECG contains other important diagnostic information (e.g. previous infarction, LV hypertrophy) that helps identify the cause of heart failure.

Echocardiography in heart failure

Echocardiography is the standard imaging modality in heart failure. It is safe, non-invasive, quick and painless for the patient. It gives many different kinds of information, but is limited in many patients by obesity, chest wall deformity and lung pathology (particularly chronic pulmonary disease). Training in echocardiography and in interpreting the results is demanding, and modern equipment is expensive. LV systolic function may be normal or globally depressed. Echocardiography may show wall motion abnormalities or ventricular dys-synchrony.

Diastolic function – the prevalence and importance of ‘diastolic heart failure’ are controversial. LV diastolic function can be assessed by examination of the mitral diastolic infl ow pattern using Doppler echocardiography, but ventricular hypertrophy and atrial dilatation are probably better markers of diastolic dysfunction.

Stress echocardiography in heart failure

ventricular impairment can result from irreversible myocardial necrosis and scarring. There may be areas of viable but non-contractile myocardium (known as ‘hibernating myocardium’) that can recover contractile function if revascularized. On dobutamine echocardiography, areas of hibernating tissue appear akinetic, but begin to function as dobutamine is infused. At higher doses, function may again be lost as the tissue becomes more ischemic. This biphasic response is highly predictive of recovery after revascularization.