Increased incidence of tuberculosis in patients undergoing hemodialysis

Clearing the clouds: Case-report and review of the literature

In peritoneal dialysis (PD), a cloudy dialysate is an alarming finding. Bacterial peritonitis is the most common cause, however, atypical infections and non-infectious causes must be considered. A 46-year-old man presented with asthenia, paraesthesia, foamy urine and hypertension. Laboratory testing revealed severe azotaemia, anaemia, hyperkalaemia and nephrotic-range proteinuria. Haemodialysis was started through a central venous catheter. Later, due to patient preference, a Tenckhoff catheter was inserted. Conversion to PD occurred 3 weeks later, during hospitalization for a presumed central line infection. A month later, the patient was hospitalized for neutropenic fever. He was diagnosed an acute parvovirus infection and was discharged under isoniazid for latent tuberculosis. Four months later, the patient presented with fever and a cloudy effluent. Peritoneal fluid (PF) cytology was suggestive of infectious peritonitis, but the symptoms persisted despite antibiotic therapy. Bacterial and mycological cultures were negative. No neoplastic cells were detected. Mycobacterium tuberculosis eventually grew in PF cultures, despite previous negative molecular tests. Directed therapy was then initiated with excellent response. Thus, facing a cloudy effluent, one must consider multiple aetiologies. Diagnosis of peritoneal tuberculosis is hampered by the lack of highly sensitive and specific exams. Here, diagnosis was only possible due to positive mycobacterial cultures.

Perioperative Management of Spinal Tuberculosis in Patients with End-Stage Renal Disease: A Preliminary Report on A Patient Series

OBJECTIVE

To present a preliminary experience of perioperative management for patients with spinal tuberculosis (STB) and end-stage renal disease (ESRD) and discuss strategic factors that should be considered.

METHODS

A retrospective study of 6 patients with STB and ESRD who underwent spine surgeries in our hospital from January 2010 to May 2017 was carried out. Medical records were reviewed for clinical manifestations, laboratory examinations, radiologic findings, perioperative management, clinical outcomes, and complications.

RESULTS

Except for 1 patient who died of cardiac arrest 5 days after surgery, this case series was followed with a mean follow-up period of 17.0 months (range, 9-23). There were no patients reporting major side effects related to an adjusted antituberculosis chemotherapy regimen. Postoperatively, surgical incision healed primarily, whereas delirium and pneumonia were noted in 2 patients. At final follow-ups, solid bony fusion was achieved in 4 patients, whereas fusion was indefinite in the patient who underwent surgery at L3/4 level. Visual analogue scale score improved from preoperative 5.2 ± 0.37 to 2.6 ± 0.55 at the final follow-ups.

CONCLUSIONS

Perioperative management of patients with STB and ESRD is a complicated issue, with multiple factors to be considered. Spinal surgery can achieve acceptable outcomes in these patients if meticulous management is performed.

Tuberculosis in renal transplant recipients: Our decade long experience with an opportunistic invader

AIM

To study the incidence, pattern of tuberculosis, Its risk factors, and prognosis in renal transplantation recipients in Indian population.

SETTINGS AND DESIGN

This study retrospectively analyzed the patients who underwent renal transplantation at Ramaiah medical college Hospitals, India from 2004 to 2015.

METHODS AND MATERIAL

The study enrolled 244 patients. Diagnosis was based on radio0imaging, sputum smear, culture and polymerase chainreaction and histology.

STATISTICAL ANALYSIS USED

A descriptive univariate analysis was performed to identify the individual risk factors.

RESULTS

The TB infection was present in 21/244 (8.6%) renal transplantation patients (mean age ± SD = 44.3 ± 12.9 years). Pulmonary tuberculosis was the commonest (57%) followed by extrapulmonary tuberculosis (43%). Type II diabetes mellitus (DM) (14.6%; p = 0.0169)was significant risk factor. Majority of the patients (n = 18, 10.7%) were on standard tripledrug immunosuppression. The median duration of anti0tubercular therapy was 14 months and crude mortality was 19%.

CONCLUSIONS

High index of suspicion for tuberculosis is require d in renal transplant recipients owing to their immunocompromised status and atypical presentations. Higher age, DM and use of immunosuppressants increase the risk for post0renal transplantation tuberculosis. Interactions between anti0tubercular drugs and immunosuppressants need to be considered in these patients.

The use of Quantiferon-TB gold in-tube test in screening latent tuberculosis among Saudi Arabia dialysis patients

BACKGROUND AND AIM

Screening for tuberculosis (TB) is a key strategy for controlling infection. This study aimed to detect latent TB among dialysis patients.

METHODS

This is a prospective study conducted in King Saud University, Riyadh involving hemodialysis (HD) and peritoneal dialysis (PD) patients aged ≥18 years. Patients were screened for latent TB infection (LTBI) using both TBskin test (TST) and QuantiFERONTB Gold In-Tube test (QFT-GIT). All participants were followed-up clinically and radiologically every 3 months for 2 years.

RESULTS

A total of 243 (181 HD and 62 PD) patients were included and 112(46.1%) were males. 45.3% showed positive QFT in HD patients with sensitivity of 91.7%, specificity of 71.4%, positive predictive value (PPV) of 19.5%, and negative predictive value (NPV) of 91.1%. TST results in HD showed that positive TST was 17.4%, sensitivity was 63.2%, specificity was 95.5%, PPV was 51.5%, and NPV was 91.1%. Five (8.1%) showed positive QFT in PD patients with sensitivity of 7.7%, specificity of 91.8%, PPV of 6.6%, and NPV of 92.3%. TST results in PD showed that positive TST was 9.8%, sensitivity was 35.7%, specificity was 97.9%, PPV was 55.8%, and NPV was 93.3%. Previous TB infection was significantly correlated with QFT only in HD patients, but significantly associated with TST in both HD and PD patients. Also in HD, QFT was significantly associated with TST (P = 0.043).

CONCLUSIONS

Due to high variability of QFT-GIT sensitivity, we recommend its use for its NPV and to use either TST or QFT in screening latent TB.

Tuberculosis in haemodialysis patients: A single centre experience

We prospectively followed-up new patients of tuberculosis while on maintenance hemodialysis at a State Government-run tertiary care institute. Between 2000 and 2010, 1237 new patients were initiated on maintainence hemodialysis. The number of patients diagnosed with tuberculosis after initiation of hemodialysis was 131 (10.5% of 1237). The age was 46.4 ± 10.4 (range 8-85) years and there were 90 (68.7%) males. The number of patients diagnosed with tuberculosis on the basis of organ involvement were: Pulmonary-60, pleural effusion-31, lymph node-21, meningitis-8, pericardial effusion-7, peritoneum-2, latent tuberculosis-2. The incidence of tuberculosis in hemodialysis was found to be 105.9 per 1000 patient years. Male gender, diabetes mellitus, past history of tuberculosis, mining as an occupation, low serum albumin, and duration of hemodialysis more than 24 months, and unemployment were found to be significant risk-factors on univariate analysis.

Heparin-binding haemagglutinin, a new tool for the detection of latent Mycobacterium tuberculosis infection in hemodialysis patients

Background

Patients with end-stage renal disease (ESRD) and latently infected with Mycobacterium tuberculosis (LTBI) are at higher risk to develop tuberculosis (TB) than healthy subjects. Interferon-gamma release assays (IGRAs) were reported to be more sensitive than tuberculin skin tests for the detection of infected individuals in dialysis patients.

Methods

On 143 dialysis patients prospectively enrolled, we compared the results from the QuantiFERON®-TB Gold assay (QFT), to those of an IGRA in response to in vitro stimulation of circulating mononuclear cells with the mycobacterial latency antigen Heparin-Binding Haemagglutinin purified from Mycobacterium bovis BCG (native HBHA, nHBHA).

Results

Seven patients had a past history of active TB and 1 had an undetermined result with both IGRAs. Among the other 135 patients, 94 had concordant results with the QFT and nHBHA-IGRA, 40.0% being negative and therefore not latently infected, and 29.6% being positive and thus LTBI. Discrepant results between these tests were found for 36 patients positive only with the nHBHA-IGRA and 5 only with the QFT.

Conclusions

The nHBHA-IGRA is more sensitive than the QFT for the detection of LTBI dialysis patients, and follow-up of the patients will allow us to define the clinical significance of discrepant results between the nHBHA-IGRA and the QFT.

Encephalopathy secondary to isoniazid in patients on hemodialysis

We report isoniazid (INH)-induced encephalopathy in two male patients on hemodialysis. One of them had tuberculous adenitis, and the other had pulmonary tuberculosis. Both were given rifampicin, INH, pyrazinamide, and ethambutol with pyridoxine 40 mg/day. Two patients developed disturbances in consciousness. After excluding other causes, INH-induced encephalopathy was suspected so the drug was stopped and dose of pyridoxine increased. Both patients retained their consciousness within 1 week and were discharged.

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

This nationwide population-based cohort study investigated the risk of tuberculosis (TB) in patients with end-stage renal disease (ESRD) and receiving dialysis. The evaluations included 4131 incident ESRD patients receiving dialysis and 16,524 age- and gender-matched controls, recruited between 1998 and 2009. We used Cox proportional hazards regression analysis to measure the association between TB and ESRD. Compared to the controls, the ESRD cohort had a significantly higher risk of TB within 1 year [incident rate ratio (IRR) 4.13], and 1-2 years (IRR 2.12), of occurrence of ESRD. The Cox proportional hazards model revealed that ESRD [hazard ratio (HR) 2.40], age >65 years (HR 2.41), male sex (HR 1.94), diabetes mellitus (HR 1.36), silicosis (HR 7.70) and chronic obstructive pulmonary disease (HR 1.61) are independent risk factors for TB. Patients with ESRD are associated with an increased risk of TB, and should thus be monitored more carefully for TB, especially within 2 years of onset of ESRD.

Mycobacterium tuberculous peritonitis in CAPD patients: a report of 11 patients and review of literature

BACKGROUND

The aims of the present report were to document our experience of the prevalence of tuberculous peritonitis in continuous ambulatory peritoneal dialysis (CAPD) patients, mode of presentation, diagnosis and outcome and to discuss the current published data about catheter removal.

METHODS

A retrospective study of CAPD patients with tuberculous peritonitis was done. A minimum of three specimens of peritoneal fluid were examined for acid-fast bacilli smears. The BACTEC 9000 Blood Culture Series of instruments were used for the culture of Mycobacterium tuberculosis. After 2005, patients were treated with anti-tuberculous treatment, and catheter retention was started in our patients.

RESULTS

There were eleven patients (2.6 %) with tuberculous peritonitis among 414 CAPD patients. M. tuberculosis accounted for 4.47 % of all peritonitis episodes. The incidence of tuberculous peritonitis was 1/794 months. There were eight males and three females. The mean age was 49 years. Intestinal obstruction was reported in two patients, and two patients were treated for antecedent peritonitis. One of them had a simultaneous fungal peritonitis. One patient each developed a peritoneo-cutaneous fistula and ultrafiltration failure. Three were successfully treated without the removal of catheter.

CONCLUSION

Based on the analysis of all published reports of tuberculous peritonitis, there was no significant difference in patient survival between patients in whom CAPD catheter was removed or retained. Tuberculous peritonitis should be considered in patients with neutrophilic 'sterile' peritonitis with no response to antibacterial medications, predominance of lymphocytic peritonitis and in bacterial peritonitis not responding to antibiotics. After an early diagnosis, with close monitoring, an effort to retain the catheter after 5 days of anti-tuberculous therapy may be attempted.

Risk stratification of latent tuberculosis defined by combined interferon gamma release assays

BACKGROUND

Most individuals infected with Mycobacterium tuberculosis develop latent tuberculosis infection (LTBI). Some may progress to active disease and would benefit from preventive treatment yet no means currently exists to predict who will reactivate. Here, we provide an approach to stratify LTBI based on IFN-γ responses to two antigens, the recombinant Early-Secreted Antigen Target-6 (rESAT-6) and the latency antigen Heparin-Binding Haemagglutinin (HBHA).

METHODS

We retrospectively analyzed results from in-house IFN-γ-release assays with HBHA (HBHA-IGRA) and rESAT-6 (rESAT-6-IGRA) performed during a 12-year period on serial blood samples (3 to 9) collected from 23 LTBI subjects in a low-TB incidence country. Both the kinetics of the absolute IFN-γ concentrations secreted in response to each antigen and the dynamics of HBHA/rESAT-6-induced IFN-γ concentrations ratios were examined.

RESULTS

This analysis allowed the identification among the LTBI subjects of three major groups. Group A featured stable HBHA and rESAT-6-IGRA profiles with an HBHA/rESAT-6 ratio persistently higher than 1, and with high HBHA- and usually negative rESAT-6-IGRA responses throughout the study. Group B had changing HBHA/rESAT-6 ratios fluctuating from 0.0001 to 10,000, with both HBHA and rESAT-6 responses varying over time at least once during the follow-up. Group C was characterized by a progressive disappearance of all responses.

CONCLUSIONS

By combining the measures of IFN-γ concentrations secreted in response to an early and a latency antigens, LTBI subjects can be stratified into different risk groups. We propose that disappearing responses indicate cure, that persistent responses to HBHA with HBHA/rESAT-6 ratios ≥ 1 represent stable LTBI subjects, whereas subjects with ratios varying from >1 to <1 should be closely monitored as they may represent the highest-risk group, as illustrated by a case report, and should therefore be prioritized for preventive treatment.

T-SPOT.TB assay usage in adults and children

The diagnosis and treatment of TB infection is one of the public health priorities. Until recently, diagnosis of TB infection has been based on the tuberculin skin test (TST). However, this is neither 100% sensitive nor specific for the diagnosis of TB infection owing to its many drawbacks. More recently, T-cell-based IFN-γ release assays (IGRAs) have been developed. In this article, we review the clinical performance of one of the IGRAs, T-SPOT.TB assay, for the diagnosis of TB infection in adults and children. We discuss the principle of the assay, its utility in active TB diseases, latent TB infection and the performance of the test in specialized subgroups of patients, such as immunocompromised individuals. When compared with the TST, the T-SPOT.TB assay has better specificity in bacillus Calmette-Guérin-vaccinated individuals, and data suggest that T-SPOT.TB may be more sensitive than the TST. Data in groups at high risk of progression to disease support the idea that T-SPOT.TB performs better than the TST. In addition, application of T-SPOT.TB by using bodily fluids such as cerebrospinal fluid, bronchoalveolar lavage fluid and pleural fluid may offer new diagnostic approaches in extrapulmonary TB disease. Although IGRAs cannot distinguish active TB disease from latent TB infection, these assays perform better than the TST for the detection of TB infection.

Tuberculin skin test, interferon-gamma assay, and T cells subpopulations in hemodialysis patients

OBJECTIVE

To examine and compare the responses of hemodialysis (HD) patients to Mycobacterium tuberculosis antigens by using the tuberculin skin test (TST) and an interferon gamma assay (IFN-TB), and to investigate the relationship between T cells subpopulations and tests results. Observational, prospective, diagnostic study conducted in a HD center in a country with high prevalence of tuberculosis.

PATIENTS

195 patients on maintenance HD who consented to participate in this study; 187 (6 were excluded for refusing TST and 2 for indeterminate responses to IFN-TB) were HIV negative, vaccinated with the Bacille Calmette-Guerin vaccine, and without any signs of active tuberculosis, were selected.

METHODS

Similar to the Mantoux method, 10 IU tuberculin was used for the TST. An IFN-gamma assay specific for Mycobacterium tuberculosis antigens and phytohemagglutinin was carried out. Flow cytometry analysis of peripheral lymphocytes was also performed.

RESULTS

TST and IFN-TB results were found to be positive (44% and 53%, respectively) or negative (32% and 47%, respectively) in similar proportions. Results were in agreement in 71% of positive and 58% of negative tests. IFN-gamma levels were found to be higher in patients with a positive TST. All cell counts and CD4/CD8 were found to be higher in TST-positive patients, whereas only total lymphocytes count and CD4/CD8 were reported to be high in IFN-TB-positive patients. A model of multivariable linear regression including cell counts explained 16% of the mitogen-induced IFN-gamma production (F = 5,11; P = .0003). The majority of subjects with positive tests were younger, in most cases male, belonged to the Roma ethnic group, had a shorter HD vintage, and a better nutritional status.

CONCLUSIONS

TST and IFN-gamma production stimulated by Mycobacterium tuberculosis antigens rely on patient's immune status, which could be influenced by either individual (age, gender), dialysis-related (HD vintage), or nutritional factors. In addition, the diagnostic utility for tuberculosis is similar and moderate in HD patients.

Incidence of fever of unknown origin and subsequent antitubercular medications in hemodialysis patients: a two-year prospective study

BACKGROUND

Hemodialysis (HD) patients are susceptible to atypical tuberculosis (TB), especially among patients presenting with fever of unknown origin (FUO), because of their impaired cellular immunity. Diagnostic trials of anti-TB drugs are therefore recommended in some TB endemic countries, including Japan, though clinical evidence for this therapy is scarce.

METHODS

We prospectively collected data for incident cases of clinical FUO for two years in 78 of 169 dialysis facilities in Aichi prefecture, located in central Japan. Clinical FUO was defined as sustained fever without any localizing signs and no infiltration on chest x-rays after a one-week antibiotic trial. The baseline characteristics, subsequent body temperatures on the days of HD therapy, and names of antibiotics including anti-TB drugs with the durations of medication were reported until fever alleviation or fever sustainment for over eight weeks.

RESULTS

We identified 15 newly developed clinical FUO patients among 8,125 HD patients. The incidence rate was estimated to be 92 (95% CI, 26-158) per 100,000 person-years. This corresponds to 244 cases per year among 264,473 HD patients in Japan. Anti-TB drugs were secondarily prescribed in 8 of 15 clinical FUO patients (53%). No improved fever alleviation was observed when anti-TB drugs were secondarily prescribed compared with cases in which other antibiotics were preferred.

CONCLUSION

We investigated the incidence of FUO in HD patients and found that the rate was not very high, whereas anti-TB drugs were frequently used for FUO cases. The efficacy of this diagnostic therapy should be elucidated in large-scale studies.

Tuberculosis in children undergoing hemodialysis

Tuberculosis (TB) remains a public health problem in Tunisia. Its incidence is higher in immunocompromised hosts than in the general population. In children and during hemodialysis, TB is characterized by the frequency of extrapulmonary localizations and diagnostic difficulties. The aim of this retrospective study is to evaluate the incidence of TB in Tunisian children undergoing hemodialysis and to determine its clinical features as well as the results of chemotherapy.

Tuberculosis in patients with end-stage renal disease undergoing dialysis in an endemic region of Turkey

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.

Fever of unknown origin in a hemodialysis patient with a failed allograft

Fever of unknown origin (FUO) in hemodialysis (HD) patients represents a diagnostic challenge because differential diagnosis includes diverse etiologies. Causes of FUO in the general population can be classified into 3 diagnostic categories: infections, tumors, and noninfectious inflammatory diseases. Also, chronic HD patients may have additional problems such as infections, the risk for which may be increased by the immunosuppression associated with uremia, vascular access-related infections, and nosocomial infections. Moreover, patients with chronically failed kidney transplants can have low-grade fever and abdominal pain, and if inflammation of the allograft is severe enough, it may result in a spontaneous rupture. Hence, it is important to rapidly recognize, diagnose, and manage these complications. In the present study, we report a case of FUO in an HD patient with a failed graft and discuss clinical approach and management of these patients.

Tuberculosis in end-stage renal disease patients on hemodialysis

Recent studies have shown that there is an increase in the incidence of mycobacterium tuberculosis (MBT). This is more prevalent among immune compromised patients (those on dialysis) and recipients of organ transplants. Furthermore, extra-pulmonary presentation appears to be more common and difficult to diagnose. We aimed in this study to assess and evaluate the presentation of MBT in a retrospective study conducted among 256 hemodialysis (HD) patients where 18 of them were diagnosed and managed for tuberculosis over a 10-year period between 1990 and 2000. The mean age of the patients was 38 years (21-75 years). The mean interval between the onset of HD and the time of diagnosis was about 24 months (1-120 months). The diagnosis of tuberculosis was made either by isolation of acid-fast bacilli (AFB), the typical caseating granuloma on biopsy, or by recovery of tubercle bacilli from the culture of the biopsy material. Extra-pulmonary tuberculosis was more common (77.8%) than pulmonary tuberculosis (22.2%). The various extra-pulmonary tuberculosis sites noted were cervical lymphadenitis (16.7%), gastrointestinal (16.7%), genitourinary (11.1%), peritonitis (11.1%), pleural effusion (5.6%), pericardial effusion (5.6%), miliary tuberculosis (5.6%), and pyrexia of unknown origin (5.6%). None of the patients with extra-pulmonary tuberculosis had evidence of pulmonary tuberculosis. The atypical presentation with insidious onset was quite common. Anergy to tuberculin skin test was noticed in 56% of cases. All of our patients received modified antituberculosis treatment for 1 year with adequate response, and without undue side effects. We conclude that a high index of suspicion is required especially in the diagnosis of extra-pulmonary tuberculosis, and when there is a high percentage of anergy to tuberculin skin test. Tissue biopsy both for characteristic histology and demonstration of MTB, either by staining or culture, remains the main criteria for the diagnosis of extra-pulmonary tuberculosis.

A boy undergoing maintenance hemodialysis who developed mediastinal lymph node tuberculosis

The incidence of tuberculosis (TBC) in patients undergoing maintenance hemodialysis is reported to be higher than that in the general population. We report an 8-year-old boy receiving such treatment for chronic renal failure who developed mediastinal lymph node TBC. He showed only intermittent fever, recurring every 2 weeks, with no other symptoms suggesting TBC. Although staining and culture of pharyngeal swab and gastric juice specimens failed to provide evidence of TBC, a lymph node biopsy specimen disclosed typical pathologic findings of tuberculoma, including caseating granulomas. Antituberculous therapy with isoniazid (INH), rifampicin, pyrazinamide, and ethambutol was given for 12 months, resulting in complete resolution of the TBC, with no subsequent recurrence. To our knowledge, mediastinal lymph node localization of TBC is relatively rare, in a patient on maintenance hemodialysis, especially in a child.

Prospective randomized control trial of isoniazid chemoprophylaxis during renal replacement therapy

BACKGROUND

Infectious diseases remain among the major morbid events in patients with end-stage renal disease (ESRD) on renal replacement therapy (RRT). In developing countries, tuberculosis (TB) has been found to occur more frequently in these patients than in the general population. Efficacy of isoniazid (INH) chemoprophylaxis has been seen in other situations, such as human immunodeficiency virus infection. However, studies on INH prophylaxis in ESRD patients on RRT are limited.

METHODS

In this prospective randomized controlled trial, from April 2000 to June 2001, a total of 109 ESRD patients registered for renal transplant and accepted for maintenance hemodialysis in our hospital were included and followed up until June 2004 to assess the role of INH prophylaxis in preventing development of TB. At the time of acceptance for hemodialysis, 54 patients were assigned to receive daily INH for 1 year and 55 patients were assigned to the control group. Primary outcome was development of TB. Secondary outcome was INH hepatotoxicity. To evaluate the effect of INH prophylaxis on the development of TB, a Kaplan-Meier survival estimate was used to plot TB-free survival curve and log-rank test was used for comparison.

RESULTS

Overall, TB was diagnosed in 27 patients during RRT, with an incidence of 24.8%. TB developed in 9 (16.7%) patients in the INH group and in 18 (32.7%) patients in the control group. There was a significantly lower incidence of TB in the INH group as compared with the control group. The risk ratio of INH vs. control group for development of TB was 0.40 (95% confidence index [CI], 0.17-0.92; P=0.032). In the INH group 27 (50%) patients and in the control group 17 (30.9%) patients developed some hepatic dysfunction. However, significant hepatitis that required discontinuation of INH developed in only 9 (16.7%) patients in the INH group. Furthermore, significant hepatitis also developed in 6 (10.9%) patients in the control group. The majority of patients with significant hepatitis in both groups (INH as well as control) were subsequently found to be positive for hepatitis B and/or hepatitis C viral infection. Mild hepatitis (which did not require discontinuation of INH) was seen in 18 (33.3%) patients in the INH group and 11 (20%) patients in the control group. Viral hepatitis infection was not found in any of the milder cases of hepatitis in either group.

CONCLUSION

This study shows significant efficacy of INH chemoprophylaxis during RRT in preventing development of TB, when the INH was started during dialysis itself. INH chemoprophylaxis was safe and well tolerated in the majority of patients. However, mild hepatic dysfunction was common, both in the treatment as well as in the control group. As the incidence of viral hepatitis overall was high in our patients on RRT, it is difficult to identify INH-induced hepatitis in this clinical setting.

Tuberculous peritonitis in a haemodialysis patient with elevated serum CA 125 and hypercalcaemia

CA 125, a glycoprotein derived from coelomic epithelium, is used primarily as a marker of epithelial ovarian cancer. However, elevated levels of serum CA 125 have also been detected in other benign and malignant disorders. This study describes a haemodialysis patient who contracted tuberculous peritonitis associated with hypercalcaemia, erythropoietin-resistant anaemia and elevated CA 125, which normalised gradually following antituberculosis treatment. Tuberculous peritonitis should be considered in the differential diagnosis of ascites with elevated serum CA 125. Additionally, CA 125 is a useful marker for monitoring response to tuberculous peritonitis treatment.

Acute and chronic influence of hemodialysis according to the membrane used on phagocytic function of neutrophils and monocytes and pro-inflammatory cytokines production in chronic renal failure patients

This work evaluated the phagocytic capacity of monocytes and neutrophils, and tumor necrosis factor-alpha, interleukin 6, 1 and 8 serum levels in chronic renal failure patients under peritoneal dialysis and hemodialysis treatment, compared with chronic renal failure patients without dialysis treatment and healthy individuals, in order to contribute to a better understanding of the action of these therapies on the evolution of chronic renal failure patients. All patients with chronic renal failure (under dialysis or not) showed decreased phagocytic capacity of neutrophils and monocytes. All those in hemodialysis (cellulose acetate or polysulfone membranes) showed a decreased phagocytic capacity. The phagocytic index for neutrophil was 13 times lower than that of the control group for both membranes, whereas for monocytes, only those using polysulfone membrane showed a significant decrease of 4.9 times in phagocytic capacity. There was an acute stimulation of the phagocytosis by neutrophils after a single session of dialysis with both types of membrane, while only cellulose acetate membrane decreased the phagocytic index of monocytes after the hemodialysis session. Patients using cellulose acetate showed a chronic increase in tumor necrosis factor-alpha serum levels, while those using polysulfone showed a chronic increase in interleukin 6. After a single hemodialysis procedure, no acute effect of the treatment on tumor necrosis factor-alpha and interleukin 6 levels was identified. The decreased phagocytic function of neutrophils and monocytes may account for the high levels of susceptibility of chronic renal failure patients to infections with pyogenic bacteria and tuberculosis. Furthermore, inflammatory activity may occur with both types of membrane studied, suggesting that it will be useful for these patients to evaluate some anti-inflammatory or anti-cytokine therapies against tumor necrosis factor-alpha and interleukin 6, in order to avoid cardiovascular complication.

Pharmacokinetic Considerations in the Treatment of Tuberculosis in Patients with Renal Failure

Tuberculosis is re-emerging in patients with altered immune status, such as those with chronic renal failure. Clinicians should thus be aware of the pharmacokinetics and dosage adjustment of antitubercular drugs in patients with renal insufficiency. Among patients with renal insufficiency, those who are dialysed should be treated with special care. Indeed, dosage should always be closely adjusted in these patients and potential removal by dialysis must be taken into account. However reliable the dosage adjustment recommendations are for these drugs in patients with renal failure, further pharmacokinetic investigations need to be performed, especially in dialysis patients in whom the influence of haemodialysis and continuous ambulatory peritoneal dialysis on drug pharmacokinetics needs to be detailed. In the meantime, it could be generally advised to administer all antitubercular drugs after the haemodialysis session, even though some drugs are known to be non-dialysable.

Tuberculosis in dialysis patients, single centre experience from an endemic area

Because of immunity defect, patients with end-stage renal disease are at increased risk of developing infections, tuberculosis (TB) in particular. The incidence of TB is higher in dialysis patients than in general population. We retrospectively reviewed the charts of dialysis patients with TB in our facility. A total of 287 dialysis patients (153 male, 134 female, 223 haemodialysis (HD), 64 continuous ambulatory peritoneal dialysis (CAPD) patients, mean age 46 +/- 15) were reviewed from October 1997 to January 2002. TB developed in 30 patients (17 male, 13 female, 24 HD and six CAPD). Thirteen patients with TB presented with fever of unknown origin (FUO) and four of them subsequently developed military lesions on chest X-ray. Nine patients had pulmonary TB (four with pleural effusions), five patients had TB lymphadenits, two patients had TB peritonitis and one patient had vertebral TB. TB was presented mostly as FUO among dialysis patients in a region under poor socio-economic conditions. In such areas with endemic TB, dialysis patients who present with FUO should be carefully evaluated for the presence of TB, and test therapy for TB should be performed in otherwise unexplained FUO.

Tuberculous peritonitis in a case receiving continuous ambulatory peritoneal dialysis(CAPD) treatment

BACKGROUND

Tuberculosis continues to be an important health problem in the world. Besides pulmonary involvement extrapulmonary involvement becomes an affair in developing countries, even in developed countries.

CASE PRESENTATION

A thirty-six year old male patient was admitted with abdominal pain, diarrhea, nausea, vomiting and fever which had started one week before. The patient had been followed up with predialisis Chronic Renal Failure(CRF) diagnosis for 4 years and receiving continuous ambulatory peritoneal dialysis (CAPD) treatment for 4 months. In peritoneal fluid, 1600/mm3 cells were detected and 70% of them were polymorphonuclear leukocytosis. The patient begun nonspesific antibiotherapy but no benefit was obtained after 12 days and peritoneal fluid bacterial cultures remained negative. Peritoneal smear was positive for Asid-fast basilli (AFB), and antituberculosis therapy was started with isoniazid, rifampicine, ethambutol and pyrazinamide. After 15 days his peritoneal fluid cell count was decreased and his symptoms were relieved. Peritoneal fluid tuberculosis culture was found positive.

CONCLUSION

Considering this case, we think that in patients with CAPD catheter and peritonitis; when peritoneal fluid leukocytes are high and PMNL are dominant, AFB and tuberculosis culture must be investigated besides bacterial culture routinely.

Tuberculosis in renal transplant recipients: rifampicin sparing treatment protocol

The reactivation of mycobacterium infection in renal transplant recipients in developing countries is a common therapeutic dilemma, especially in those patients receiving cyclosporin immunosuppression. The inclusion of rifampicin in the antituberculosis protocol increases the risk of precipitating acute allograft rejection due to its interaction with cyclosporin and also increases the financial burden. We successfully treated 16 patients who developed mycobacterial infection post renal transplant with a rifampicin sparing antituberculosis drug regimen. Pyrexia of unknown origin was the most common manifestation observed and a therapeutic trial with antituberculosis drugs is justified. De novo diabetes mellitus appears to be an added risk factor and increases the susceptibility to mycobacterial infection.

The booster phenomenon in 2-step tuberculin skin testing of patients receiving long-term hemodialysis

BACKGROUND

Tuberculosis remains a significant health problem for patients receiving long-term hemodialysis (HD). The tuberculin skin test (TST) is an important method for detecting Mycobacterium tuberculosis infection. This study examined the significance and frequency of the booster phenomenon in serial TST of HD patients.

METHOD

Fifty-three outpatients in a hospital-based HD center in Turkey were screened for tuberculosis with the TST between August and October 1999. To determine the frequency of booster phenomenon, patients with less than 10 mm indurations to the initial TST were given a second test 7 days later.

RESULTS

Nineteen (35.8%) of 53 patients had a significant tuberculin reaction (> or = 10 mm) on the initial TST. The booster effect was detected in 10 (29.4%) of 34 patients who had a negative reaction (< 10 mm) to the initial test. Overall, 29 (54.7%) patients showed a significant reaction on both tests.

CONCLUSIONS

These results showed significant rates of TST positivity and the booster effect in this HD center.

Therapeutic drug monitoring in the treatment of tuberculosis

Therapeutic drug monitoring (TDM) is a standard clinical technique used for many disease states, including many infectious diseases. As for these other conditions, the use of TDM in the setting of tuberculosis (TB) allows the clinician to make informed decisions regarding the timely adjustment of drug therapy. Such adjustments may not be required for otherwise healthy individuals who are responding to the standard, four-drug TB regimens. However, some patients are slow to respond to treatment, have drug-resistant TB, are at risk of drug-drug interactions or have concurrent disease states that significantly complicate the clinical situation. Such patients may benefit from TDM and early interventions may preclude the development of further drug resistance. It is not possible to collect multiple blood samples in the clinical setting for logistical and financial reasons. Therefore, one typically is limited to one or two time points. When only one sample can be obtained, the 2-hour post-dose concentrations of isoniazid, rifampin, pyrazinamide and ethambutol are usually most informative. Unfortunately, low 2-hour values do not distinguish between delayed absorption (late peak, close to normal range) and malabsorption (low concentrations at all time points). A second sample, often collected at 6-hour post-dose, can differentiate between these two scenarios. The second time point can also provide some information about clearance and half-life, assuming that drug absorption was nearly completed by 2 hours. TDM requires that samples are promptly centrifuged, and that the serum is promptly harvested and frozen. Isoniazid and ethionamide, in particular, are not stable in human serum at room temperature. Rifampin is stable for more than 6 hours under these conditions. During TB treatment, isoniazid causes the greatest early reduction in organisms and is considered to be one of the two most important TB drugs, along with rifampin. Although isoniazid is highly active against TB, low isoniazid concentrations were associated with poorer clinical and bacteriological outcomes in US Public Health Services (USPHS) TB Trial 22. Several earlier trials showed a clear dose-response for rifampin and pyrazinamide, so low concentrations for those two drugs also may correlate with poorer treatment outcomes. At least in USPHS TB Trial 22, the rifampin pharmacokinetic parameters were not predictive of the outcome variables. In contrast, low concentrations of unbound rifapentine may have been responsible, in part, for the worse-than-anticipated performance of this drug in clinical trials. The 'second-line' TB drugs, including p-aminosalicylic acid, cycloserine and ethionamide, are relatively weak TB drugs. Under the best conditions, treatment with these drugs takes over 2 years, as opposed to 6 to 9 months with isoniazid- and rifampin-containing regimens. Therefore, TB centres such as National Jewish Medical and Research Center in Denver, CO, USA, measure serum concentrations of the 'second-line' TB drugs early in the course of treatment. That way, poor drug absorption can be dealt with in a timely manner. This helps to minimise the time that patients are sputum smear- and culture-positive with multidrug-resistant TB, and may prevent the need for even longer treatment durations. Patients with HIV are at particular risk for drug-drug interactions. Because the published guidelines typically reflect interactions only between two drugs, these guidelines are of limited value when the patient is treated with three or more interacting drugs. Under such complicated circumstances, TDM often is the best available tool for sorting out these interactions and placing the patient the necessary doses that they require. TDM is only one part of the care of patients with TB. In isolation, it is of limited value. However, combined with clinical and bacteriological data, it can be a decisive tool, allowing the clinician to successfully treat even the most complicated TB patients.

Encephalopathy caused by isoniazid in a patient with end stage renal disease with extrapulmonary tuberculosis

Tuberculosis infection is common in patients on maintenance hemodialysis, and the extrapulmonary presentations, which is usually asymptomatic, and only mild clinical presentation, are not uncommon. These hemodialysis patients were always prescribed multiple antituberculosis agents, including isoniazid, rifampin, ethambutol, and pyrazinamide, alongside their usual medication. Conscious disturbance was also frequently observed in these patients, with different paramount etiologies in the pre- and post-hemodialysis phases. We report a case undergoing maintenance hemodialysis, showing disturbed consciousness ten days following antituberculosis treatment for his established extrapulmonary tuberculosis infection. Consciousness was regained seven days later, after discontinuation of isoniazid.

Tuberculosis and chronic renal disease

There is an increased risk (6.9- to 52.5-fold) of tuberculosis (TB) in patients with chronic renal failure and on dialysis as compared to the general population. The symptomatology in renal patients is often insidious and nonspecific, mimicking uremic symptoms, whereas the localization is often extrapulmonary (most frequently tuberculous lymphadenitis and peritonitis). Tuberculous peritonitis makes up a large part (37%) of the total number of TB cases in continuous ambulatory peritoneal dialysis (CAPD) patients. The prognosis is very much dependent on early diagnosis and treatment. Renal physicians should be aware of the unusual presentation and localization, and include TB in the differential diagnosis of any patient having nonspecific symptoms like anorexia, fever, and weight loss. All efforts should then be made (including invasive investigations) to reach an early diagnosis, a major determinant of the outcome. However, if this is not possible or the result is negative and the diagnosis remains strongly suspected, an empirical trial with anti-TB medication is justified, especially in endemic areas. In view of the increased prevalence of the disease in the dialysis population, TB prophylaxis is recommended in those patients with a positive tuberculin (Mantoux) skin test and radiographs suggestive of old TB.

Tuberculous arthritis mimicking neoplasm in a hemodialysis patient

Hemodialysis patients are known to develop the complication of extrapulmonary tuberculosis more frequently than the general population. Tuberculous arthritis is a rare form of extrapulmonary tuberculosis and is reported to occur in approximately 1% of cases in nonuremic patients. Only 3 cases in dialysis patients, who were not proven by a bacterial culture or had died before treatment, have been reported. We report herein a culture-proven case of tuberculous arthritis developing at the sternoclavicular joint, which initially mimicked an apparent neoplasm in a hemodialysis patient. A favorable outcome was obtained after antituberculous therapy. Tuberculosis must be considered one of the most significant diagnoses in hemodialysis patients who present with a tumor-like lesion.

Tuberculosis infection in Chinese patients undergoing continuous ambulatory peritoneal dialysis

A retrospective study of the prevalence and pattern of tuberculosis in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) was performed. Thirty-eight cases of tuberculosis were diagnosed among 790 patients (18 men, 20 women; mean age, 58 +/- 12.6 years) between July 1994 and June 2000. The interval between the initiation of CAPD and onset of tuberculosis ranged from 1 to 168 months (median, 22 months). There were 18 cases of pulmonary tuberculosis, 14 cases of tuberculous peritonitis, 5 cases of tuberculous lymphadenitis, and 1 case of tuberculous synovitis. Patients with pulmonary tuberculosis usually presented with fever, constitutional symptoms, and pleural effusion or pulmonary infiltrates on chest radiograph. Abdominal pain and turbid dialysate were the main presenting symptoms in patients with tuberculous peritonitis. Diagnosis was established by positive culture in 20 patients, typical histological characteristics on a tissue biopsy specimen in 10 patients, and response to empirical antituberculous treatment in 8 patients. The duration of symptoms before the diagnosis of tuberculosis and initiation of antituberculous treatment ranged from 7 to 57 days (median, 30 days). Antituberculous treatment consisted of isoniazid, rifampicin, pyrazinamide, and ofloxacin for 9 to 15 months. Antituberculous treatment generally was well tolerated. Twenty-seven patients (71%) completed antituberculous treatment. No recurrence of tuberculosis was observed after a mean follow-up of 19.8 months. Eleven patients (29%) died while on antituberculous treatment; none of the deaths appeared to be directly caused by tuberculosis. We conclude that: (1) tuberculosis is prevalent among CAPD patients in our locality; (2) extrapulmonary tuberculosis, particularly tuberculous peritonitis, is common; and (3) a high index of suspicion for tuberculosis among CAPD patients is warranted to ensure early diagnosis and prompt initiation of treatment.

Mycobacterial infections in patients with chronic renal disease

In this article, the authors have provided a comprehensive review of TB and MOTT infections in patients on renal dialysis and receiving kidney transplants. Because most published series are small retrospective studies or case reports, there are several uncertainties still involved in the diagnosis and treatment of such patients. Unanswered questions include selection of optimal dosage and duration of therapeutic agents; the best tests for screening and diagnosis, especially in high prevalence areas; and the best management of MOTT infections because of unavailability of highly effective therapy.

Extrapulmonary tuberculosis in patients with end stage renal disease--two case reports and a brief review

Chronic renal failure is a risk factor for tuberculosis. In the past five years we have identified two cases of tuberculosis in our dialysis population. The first patient, showed chronic failure to thrive on hemodialysis. An enlarged cervical lymph node was biopsied and, although no acid fast bacilli (AFB) were seen, a culture grew Mycobacterium tuberculosum (TB). Her chest X-ray did not show evidence of past tuberculosis. The second patient was a long time smoker who presented with an enlarged cervical node, which was biopsied. AFB were not seen on her biopsy, but her culture grew TB. Extrapulmonary TB is common in patients with ESRD, and lymph node involvement is the most common extrapulmonary presentation. Screening with the purified protein derivative (PPD) is not helpful in ESRD patients, since defects in cell mediated immunity are common. A high index of suspicion for TB is warranted in patients with ESRD.

Peritoneal tuberculosis in patients receiving continuous ambulatory peritoneal dialysis

BACKGROUND

Patients with chronic renal failure have an increased risk of tuberculosis (TB). This occurs with much higher frequency within the first 12 months of initiating dialysis and is usually extrapulmonary in nature. Patients most at risk are those from susceptible ethnic groups, especially the Indian subcontinent. Peritoneal TB, otherwise relatively uncommon, has emerged as an important form of TB in patients undergoing continuous ambulatory peritoneal dialysis (CAPD).

METHODS

All cases of peritoneal TB occurring at our institution in patients undergoing CAPD over a 13 year period were identified and analysed.

RESULTS

Eight cases were identified, of which seven were non-Caucasian. These patients' characteristics and outcomes are presented. All were undergoing CAPD and most developed TB within 12 months of initiating dialysis. All presented with fever, but symptoms and signs were indistinguishable from bacterial peritonitis. Six were culture-positive, mainly from peritoneal dialysis fluid, but only two cases proved smear-positive. All were treated with standard anti-tuberculous chemotherapy. Three went on to permanent haemodialysis as a result of peritonitis and three have died, one of these as a result of TB.

CONCLUSIONS

Peritoneal TB, whilst otherwise relatively uncommon, is an important manifestation of TB in CAPD patients and usually develops soon after commencing dialysis. The reasons for this are unknown and require further research.