Tuberculosis in Patients With End-Stage Renal Disease Undergoing Dialysis in an Endemic Region of Turkey

doi:10.1016/j.transproceed.2007.12.003

Transplantation Proceedings

Volume 40, Issue 1, January–February 2008, Pages 81-84

https://doi.org/10.1016/j.transproceed.2007.12.003 Get rights and content

Abstract

The incidence of tuberculosis (TB) is high in end-stage renal disease (ESRD) patients undergoing dialysis. Diagnosis is difficult and delayed in this patient group owing to extrapulmonary involvement and nonspecific symptoms. Adverse effects of antituberculosis treatment are seen more frequently in these patients. We retrospectively evaluated the frequency and clinical progression of TB in 18 of 343 dialysis patients diagnosed with TB over a 5-year period at a university hospital in Adana, Turkey. Mean time between initiation of dialysis to diagnosis of TB was 19.5 ± 26.1 months. Extrapulmonary TB was more frequent (77.8%) than pulmonary TB (22.2%). Diagnosis of TB was made based on clinical data in 1 patient, and microbiologically or pathologically in others. Antituberculosis treatment with 3 or 4 drugs was administered to patients for 6 to 12 months; second-line treatment was initiated in 1 patient infected with multidrug-resistant bacilli. One patient died owing to a cause other than TB; another was lost to follow-up. Adverse effects were hepatotoxicity in 3, optic neuritis in 1, and neuropsychiatric in 3 patients. A clinical response to therapy was achieved in all of the 16 patients who completed treatment. In conclusion, the incidence of TB and the frequency of extrapulmonary involvement are high in dialysis patients. Physicians must be alert to unusual presentations and localizations of the disease; TB must be strongly suspected in endemic regions. Owing to the greater frequency of adverse effects of treatment in these patients, they must be carefully observed during treatment.

Section snippets

Materials and Methods

Adana in the southern part of Turkey is a district known for its influx of people from the inner country. We evaluated the data of 18 patients diagnosed with TB out of 343 patients on regular HD or CAPD between January 2001 and January 2006 at the Baskent University Faculty of Medicine, Adana, Turkey. We recorded the demographic characteristics; form of dialysis; date of initiation of dialysis; period of time between initiation of dialysis to diagnosis of TB; and the results from routine

Results

The clinical characteristics of our patients are shown in Table 1. TB was diagnosed in 18 of 343 patients (5.2%) undergoing dialysis. The patients underwent HD 3 days/week or CAPD 4 times/day.

Evaluation of the chest radiographs of 4 patients with pulmonary TB revealed apical infiltration in 3 and a cavitary lesion with infiltration in 1. Pleural effusion was present in 1 of the patients with infiltration. TB meningitis accompanied pulmonary TB in the patient with the cavitary lesion. Two

Discussion

ESRD patients are more susceptible to respiratory infections than are people in the general population owing to pathological changes in the airway and impairment of cellular immunity.⁹ Although some studies report that the incidence of TB does not increase in dialysis patients,10, 11 a recently published summary article reported that the incidence of TB is 6.9- to 52.5-fold greater in dialysis patients compared with the general population.¹ Geographic, ethnic, and social factors may be reasons

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Cited by (28)

Tuberculosis incidence in patients with chronic kidney disease: a systematic review and meta-analysis.
2022, International Journal of Infectious Diseases
Citation Excerpt :
Furthermore, TB incidence among patients on peritoneal dialysis was reported in 18 studies, with a sample size ranging from 18 (Sen et al., 2008) to 25,704 (Klote et al., 2006). TB incidence in this group ranges from 310 per 100,00033 (Ahmed and Karter, 2004) to 22,220 per 100,000 (Sen et al., 2008). Among 35,086 patients on peritoneal dialysis, 509 developed TB, which gave a pooled estimate of 3533 per 100,000 (95%CI; 2220, 4846, I2; 86.29%) (Table 1, Figure 11).
The aim of this study was to estimate global TB incidence in patients with CKD.
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method was followed to perform the study. Electronic and gray literature sources were investigated for studies published between 2000 and 2021. The Joanna Briggs Institute critical appraisal checklist was used to assess the quality of the studies, and STATA version 16 was used for analysis. The I² heterogeneity test was employed to assess heterogeneity. To examine publication bias, funnel plots and Egger's regression tests were performed.
A total of 104 studies with a sample size of 1,548,774 were included. TB incidence in patients with CKD ranges from 60 per 100,000 in the UK to 19,270 per 100,000 in China. The pooled TB incidence was estimated as 3718 per 100,000 (95%CI; 3024, 4411). Higher pooled TB incidence was found in the African region (9952/100,000, 95%CI; 6854, 13,051), followed by the South-East Asian (7200/100,000, 95%CI; 4537, 9863) and Eastern Mediterranean (5508/100,000, 95%CI; 3470, 7547) regions. In particular, patients on hemodialysis (5611/100,000) and on peritoneal dialysis (3533/100,000) had higher incidence of TB than did renal transplantation patients (2700/100,000) and patients with predialysis CKD (913/100,000). Furthermore, extrapulmonary TB (2227/100,000) was more common than pulmonary TB (1786/100,000).
This study identifies high TB incidence in patients with CKD with regional disparities. Thus, the authors recommend active TB screening in this group of individuals.
Tuberculosis among chronic hemodialysis patients in Togo: Report of 10 cases
2017, Nephrologie et Therapeutique
Déterminer la fréquence de la tuberculose chez les hémodialysés au Togo, préciser ses différentes localisations et les difficultés de sa prise en charge.
Il s’agit d’une étude rétrospective sur une période de 5 ans (2010–2015), incluant les patients hémodialysés chroniques à l’unité d’hémodialyse du service de néphrologie du Centre hospitalier universitaire Sylvanus-Olympio de Lomé. Le diagnostic de la tuberculose a été retenu sur la base des données cliniques et paracliniques. Le traitement spécifique a comporté l’association de 4 antituberculeux, dont les posologies étaient adaptées à la fonction rénale.
Sur 91 patients hémodialysés chroniques durant la période de l’étude, 10 cas de tuberculose ont été colligés, soit une fréquence de 10,9 %. L’âge moyen était de 37,3 ± 12,8 ans, avec un sex-ratio égal à 1,5. Le délai entre le début de l’hémodialyse et la survenue de la tuberculose était en moyenne de 16,8 ± 9 mois. La localisation de la tuberculose était extrapulmonaire (5 avaient à la fois une localisation péritonéale et pleurale ; 5 avaient uniquement une localisation pleurale) chez tous nos patients. L’intradermoréaction était positive chez 4 patients (40 %). La recherche de bacille de Koch était infructueuse dans tous les types de prélèvements. Le traitement antituberculeux a été globalement toléré. Deux patients (20 %) sont décédés en cours de traitement.
La tuberculose est relativement fréquente chez l’hémodialysé. Le diagnostic est difficile et peut reposer sur l’épreuve thérapeutique.
To determine the frequency of tuberculosis among hemodialysis patients in Togo, specify its different localizations and identify its diagnostic and therapeutic difficulties.
This was a retrospective study over a period of 5 years (2010–2015). It includes the records of periodic hemodialysis patients in the Nephrology Department of the Sylvanus-Olympio University Teaching Hospital in Lomé. The diagnosis of tuberculosis was selected on the basis of clinical and laboratory data. The specific treatment has involved the association of 4 antituberculosis, which was adapted to the renal function.
Of 91 chronic hemodialysis patients treated in Hospital Sylvanus-Olympio hemodialysis center, 10 cases (10.9%) of tuberculosis were diagnosed. The mean age was 37.3 ± 12.8 years, and the sex ratio was 1.5. The median time to onset of tuberculosis after initiation of hemodialysis was 16.8 ± 9 months. Extrapulmonary sites are found in 100% of cases (5 had both peritoneal and pleural localization, only 5 had pleural localization). The tuberculin skin test was positive in 4 patients (40%). The search for Mycobacterium tuberculosis was unsuccessful in all types of samples. Tuberculosis treatment was generally tolerated. Two patients (20%) had died during treatment.
Tuberculosis is relatively common in hemodialysis patients. Diagnosis is difficult and may be based on the therapeutic trial.
Hepatotoxicity from antituberculous therapy in the elderly: A systematic review
2015, Tuberculosis
Citation Excerpt :
Three-hundred and twenty-one full text selections were further reviewed. However, many did not meet the study criteria due to the absence of measurable data on hepatotoxicity or failure to specify age-specific groups/events under comparison, leaving 38 studies for which we were able to obtain full datasets from the authors or article [7–44]. These included 40,034 participants with 1208 cases of hepatotoxicity, of which 339 occurred in those over the age of 60.
Elderly persons have the highest rates of tuberculosis (TB) in the United States compared to all other age groups. A systematic literature review was conducted to determine if older age was a risk factor for hepatotoxicity resulting from treatment with first-line drugs used to treat active (TB) and latent tuberculosis (LTBI).
A systematic review of MEDLINE, Cochrane Controlled Trial Registry, CINAHL^®, and Science Citation Index Expanded (from 1970 to 2011) was performed to determine the risk of hepatotoxicity, comparing those over 60 with those under 60. A meta-analysis was performed using a random effects model along with log odds ratios and the chi-square test.
Thirty-eight studies (40,034 participants; 1208 cases of hepatotoxicity) met the selection criteria. For active TB, an overall mean effect of 0.277 (p = 0.024, 95% CI: 0.037–0.517) was observed, which is equivalent to an odds ratio of 1.32 (95% CI: 1.04–1.68). For LTBI, an overall mean effect of 1.42 (p < 0.001, 95% CI: 0.794–2.05) was observed, which translates to an odds ratio of 4.14 (95% CI: 2.21–7.74).
Our analysis revealed that patients older than 60 had significantly more risk of hepatotoxicity. These studies suggest that a gentler regimen of treatment for older individuals could benefit health outcomes in this population of TB patients and minimize risks to the public's health.
Mycobacterium tuberculosis infection of end-stage renal disease patients in Taiwan: A nationwide longitudinal study
2011, Clinical Microbiology and Infection
Citation Excerpt :
Among all notifiable infectious diseases, MTB infection has the greatest number of confirmed cases per year, with more than 15 000 new infections per year. ESRD patients are vulnerable to MTB infection, but previous studies have reported very different RR rates [23–26], mainly because of the small sizes of these studies. An exception is the cross-sectional study conducted by Chou et al. [27], which examined Taiwan CDC MTB registration data and indicated an annual MTB infection rate of 24 533 Taiwanese HD patients of 0.5 per 1000 patients in 2001.
End-stage renal disease (ESRD) patients are vulnerable to Mycobacterium tuberculosis (MTB) infection, but the magnitude of the risk is uncertain. In addition, there is no reliable information on the MTB infection rate of patients undergoing different types of renal replacement therapy (RRT). We used the Taiwan National Health Insurance Research Database to conduct a 9-year nationwide longitudinal study. Among 49 983 ESRD patients who received three renal replacement modalities, there were 562 cases of MTB infection, corresponding to an incidence rate of 3.0 per 1000 patient-years. The risk of MTB infection relative to the general population was 4.5. Multivariate Cox regression analysis indicated that the independent risk factors for MTB infection in ESRD patients are old age (hazard ratio (HR) 1.17 per 10 years, p <0.001), male gender (HR 1.37, p <0.001), silicosis (HR 5.82, p <0.001), and chronic obstructive pulmonary disease (HR 1.68, p 0.012). Hyperlipidaemia (HR 0.71, p <0.001) and hypertension (HR 0.81, p 0.05) are associated with a lower infection rate. There was no effect of RRT modality on MTB infection rate.
Drugs used in tuberculosis and leprosy
2010, Side Effects of Drugs Annual
Citation Excerpt :
There was chronic allograft dysfunction in 34 patients, 19 with graft loss. In a retrospective study in Turkey, tuberculosis occurred in 18 of 343 dialysis patients (39c). The mean time between the start of dialysis to the diagnosis of tuberculosis was 20 months.
This chapter describes the adverse effects of drugs used in tuberculosis and leprosy, such as dapsone, cycloserine, ethambutol, isoniazid, and rifamycins. The pharmacokinetics of topical 5% dapsone gel has been studied in 548 patients with acne vulgaris in three open prospective studies. The authors concluded that topical application of dapsone gel in various settings ranging from 2 weeks to 12 months resulted in systemic exposure to dapsone and its metabolites approximately 100-fold less than after oral dapsone even in the presence of a therapeutic dose of co-trimoxazole. A review of 101 patients with clinical and electrophysiological findings suggestive of ethambutol retinopathy has been reported. Hypothryroidism has been associated with rifampicin. Rifampicin induces hepatic oxidases and the metabolic clearance rate of T4 by increased iodothyronine conjugate biliary excretion. Hypothyroidism induced by rifampicin, although rare, has to be considered, and thyroid function should be checked if symptoms of hypothyroidism occur. It appears to be reversible, and levothyroxine can be withdrawn after treatment with rifampicin has been completed.
Increased risk of tuberculosis in patients with end-stage renal disease: A population-based cohort study in Taiwan, a country of high incidence of end-stage renal disease
2014, Epidemiology and Infection

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Renal transplantationCandidateTuberculosis in Patients With End-Stage Renal Disease Undergoing Dialysis in an Endemic Region of Turkey

Abstract

Section snippets

Materials and Methods

Results

Discussion

Am J Med

Clin Chest Med

Transplant Proc

Am J Kidney Dis

Tuberculosis and chronic renal disease

Semin Dial

Increased incidence of tuberculosis in patients undergoing hemodialysis

Nephron

Tuberculosis in active dialysis patients in Jeddah

Am J Nephrol

Side-effects of antituberculosis drug treatment in patients with chronic renal failure

Eur Respir J

Global tuberculosis control: surveillance, planning, financing. WHO Report 2007

Trends in tuberculosis—United States, 2005

MMWR Morb Mortal Wkly Rep

Renal transplantation
Candidate
Tuberculosis in Patients With End-Stage Renal Disease Undergoing Dialysis in an Endemic Region of Turkey