Tuberculosis in Hemodialysis Patients in Area of High Incidence of Mycobacterium tuberculosis and Human Immunodeficiency Virus Infection

Abstract

BACKGROUND Hemodialysis (HD) patients have an increased incidence of tuberculosis (TB), which may be due to decreased cellular immunity, the presence of malnutrition, and the use of immunosuppressive drugs. Poor living conditions, overcrowding, and human immunodeficiency virus (HIV) infection could be considered added risk factors. This study analyzed the incidence and clinical characteristics of TB among HD patients in an area where TB and HIV infection have a high prevalence. METHODS In this multicenter study, 1266 patients (663 men and 603 women) ages 20–91 years (46.1 ± 16.8 years) from 8 HD centers in different cities of Rio de Janeiro State, Brazil, were studied. HIV‐infected patients were excluded from the study. RESULTS TB was observed in 30 patients (2.3%), the pulmonary type in 11 (36.6%) and the extrapulmonary type in 19 (63.4%). The time of emergence during the HD period was very wide (2–117 months). All patients presented with unexplained fever and general symptoms such as weight loss, fatigue, and malaise in variable frequencies. The purified protein derivative (tuberculin) test was positive in only 16.6% of TB patients. They were treated with a combination of rifampicin (450–6000 mg/day), isoniazid (200–300 mg/day), and pyrazinamide (1.5–2 g/day); only 1 patient died, and 2 underwent a successful renal transplantation after the treatment. CONCLUSIONS TB incidence in HD patients was higher than in the general population (p < 0.0001) with a relative risk (RR) of 19.68 (13.81 < RR < 29.03), which points to the urgent need to investigate TB in all uremic patients with unexplained fever, continuous nonspecific symptoms, or when TB is suspect, whereas the response to therapy is directly dependent on early diagnosis, and the specific treatment may offer HD patients a good prognosis.

Tuberculosis among Chronic Hemodialysis Patients: A Senegalese Single Center Experience

“…In our series, the prevalence of TB was 56.2 times higher than in the Senegalese general population where it is estimated to be 200/100,000. The high prevalence of TB in the CHD patients compared to the general population was confirmed by other authors [3] [7] [10] [11] [15]. A literature review reported that the incidence is 6.9 to 52.5 times higher in dialysis patients [16].…”

“…In addition to the poor specificity of symptoms, also the site of TB is often extra-pulmonary. In the literature, this frequency varies from 47% to 100%; the lymph node and peritoneal tuberculosis are the most common sites [3] [5] [9] [11] [15]. In our study, the extrapulmonary location was predominant (79%).…”

“…In our study, the extrapulmonary location was predominant (79%). All the authors reported the difficulty in the diagnosis of TB in the CHD; it is due to non-specific symptoms and the frequency of extrapulmonary location [3] [15]. In our series sure diagnosis was only achieved in 17% of patients, 7% bacteriology, 7% on tissue biopsy histology and 3% at autopsy.…”

“…The protocols and duration of antituberculosis treatment vary according to the authors. Some associate RHZ [11] [15], others RHZE [5] [10] [11] for the first two months, and HR during the maintenance phase. Dosages of R and H should not be changed, while the Z and E are respectively administered at the dose of 30 mg/kg and 20 mg/kg every 48 hours.…”

“…The combination of immune deficiency, malnutrition and tuberculosis infection increases the risk of tuberculosis and mortality [3] [9] [11]. The death rate ranges from 0% -75% according to studies [8]- [11] [15]. It is often attributed to delayed diagnosis and treatment.…”