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.

Tuberculosis was diagnosed in 23 of 205 patients undergoing maintenance dialysis, an incidence of 11%. Seventeen patients (74%) were females. It was characterised clinically by a very insidious onset, the main symptoms being anorexia, loss of weight, and low-grade fever. There were extrapulmonary presentations in 18 of the 23 patients (78%). Tuberculous lymphadenitis predominated in the extrapulmonary form (55%) with peritoneal involvement coming second in frequency (16%). Pulmonary tuberculosis was seen in five patients (21.7%), four of them presenting with pleural effusions. Total white cell and differential count was normal in all patients studied. Most of the patients developed the disease about 1 year from the start of their dialysis treatment. With early therapy all patients survived their tuberculous disease and no recurrence was seen in up to 5 years follow-up. Despite earlier reports of high mortality we suggest that awareness of the increased incidence of tuberculosis in dialysis patients, together with its unusual presentation and consequent early diagnosis, results in a very good prognosis.

In contrast to Europe and the USA, data concerning dialysis treatment in Middle Eastern countries like Saudi Arabia are lacking. We therefore studied 325 patients (150 females and 175 males) in one dialysis centre over a 13-year period. The number of primary renal diseases of uncertain aetiology and of pyelo/interstital nephritis caused by renal stone disease was high (46% and 4.9% resp.), that of diabetic nephropathy (14.8%) not much different from EDTA figures, while adult polycystic kidney disease was seen in only four patients (1.2%, versus EDTA: 5.5%). Sixty-one percent needed antihypertensive medication to control the blood pressure, less than reported by the EDTA. Nineteen patients (5.8%) had pericarditis, 38% radiographic signs of renal bone disease and eight patients required parathyroidectomy. Only two patients had carpal tunnel syndrome. Over the 13-year period the number of HBsAg-positive patients was 14%, reflecting the high prevalence of this disease in the country, but in the last 4-5 years the incidence dropped markedly (3% in 1993). In 1993, 40% of the 67 patients on dialysis had hepatitis C (HCV) antibodies of which 19 (70%) were HCV-RNA positive. Although tuberculosis (mainly extra-pulmonary) was common (9.2%), no patient died because of this disease. Cardiovascular factors contributed in the same degree to the causes of death as in Europe: 63% versus 62%. One hundred and fourteen patients (35%) had a successful kidney transplant.

No abstract

cT-I has a high specificity for the diagnosis of myocardial infarction in dialysis patients. Despite the relatively low number of positive test results, cT-I was found to be significantly correlated with the outcome all-cause mortality at 1 year.

The simultaneous occurrence of acute poststreptococcal glomerulonephritis and acute rheumatic fever is a rarity. We report here such an occurrence in a 9-year-old Saudi boy whose kidney biopsy showed diffuse exudative glomerulonephritis with subepithelial humps on electron microscopy in the presence of active rheumatic carditis.

No abstract

Dialysis patients with troponin-I levels above the cut-off value diagnostic for acute myocardial event (AME) are sometimes labeled as having "renal cause" of elevated troponin-I. Patients with troponin-I levels above 0.0 ng/mL, but below the cut-off level for an AME, are reported to have increased risk for coronary heart disease and mortality. Single pre-dialysis blood samples were taken from 150 asymptomatic dialysis patients (on hemo- or peritoneal dialysis) for troponin-I, cardiac enzymes, C-reactive protein (CRP) and lipid parameters. Troponin-I was measured by a chemiluminescent microparticle immunoassay (CMIA), of which the cut-off value for AME was set at ≥0.4 ng/mL. Patients with troponin-I levels of 0.0 ng/mL, and those with levels between 0.1 and 0.3 ng/mL, were compared regarding their cardiovascular risk profile. None of the patients had troponin-I concentrations above the cut-off level diagnostic for an AME, with 85.3% of the patients having levels of 0.0 ng/mL. While there was no difference in the "traditional" risk factors such as age, body mass index, prevalence of diabetes mellitus, hypertension, total cholesterol and low-density lipoprotein cholesterol between patients with troponin-I levels of 0.1-0.3 ng/mL and those with levels of 0.0 ng/mL, CRP concentrations were higher in the former. In peritoneal dialysis patients, the weekly Kt/V was lower in the patients with troponin levels between 0.1 and 0.3 ng/mL. The findings should add strong support in settling the debate of whether or not in patients on dialysis, falsely elevated levels of troponin-I "commonly" occur. An increased level of CRP and lower Kt/V might add to the cardiovascular risk in patients with troponin-levels between 0.1 and 0.3 ng/mL.