| Abstract|| |
This retrospective study was performed to review the prevalence, clinical presentation and outcome of tuberculosis (TB) in patients on maintenance hemodialysis (HD) as compared to that of the general population in Jordan. The records of 927 patients who were maintained on maintenance HD at King Hussein Medical Center between 1986 and 1993 were reviewed for the development of TB. There were 550 males and 377 females in the study group. Eleven of these patients (1.2%) were diagnosed to have TB during this period. This figure is higher than the prevalence rate of 0.015% reported among the general population in some regions of Jordan. Of the 11 patients with TB, there were four males and seven females. Their ages varied from 28 to 70 years and the duration on maintenance HD before the onset of TB ranged between 1 and 24 months. Extra-pulmonary manifestations predominated (81.8%) and TB lymphadenitis was the commonest lesion observed. Five patients died during the study period but none due to a direct consequence of TB or its treatment. We conclude that the prevalence of TB is high among patients on HD In Jordan when compared with the general population.
Keywords: Tuberculosis, Hemodialysis, Prevalence.
|How to cite this article:|
Akash N, Smadi I, Hadidi M, Afara H, El-Lozi M. Tuberculosis in Patients on Maintenance Hemodialysis: A Single Center Experience. Saudi J Kidney Dis Transpl 1996;7:20-3
|How to cite this URL:|
Akash N, Smadi I, Hadidi M, Afara H, El-Lozi M. Tuberculosis in Patients on Maintenance Hemodialysis: A Single Center Experience. Saudi J Kidney Dis Transpl [serial online] 1996 [cited 2020 Jun 1];7:20-3. Available from: http://www.sjkdt.org/text.asp?1996/7/1/20/39534
| Introduction|| |
Patients undergoing chronic dialysis have a high incidence of serious infection due to impaired host defense mechanisms which may be related to their impaired cell-mediated and humoral immunity ,,, . Depressed cellular immunity has been associated with infections due to Mycobacterium tuberculosis up> ,, . Studies have shown that tuberculosis (TB) occurs with greater frequency among patients with chronic renal failure than in a random population  . Also, reports have suggested that both pulmonary and extrapulmonary TB occur with increased frequency in patients on chronic hemodialysis (HD) ,, . The common symptoms associated with patients on regular dialysis such as pyrexia, weight loss and general malaise may mask or mimic the symptoms of TB. Cutaneous reactions to tuberculin are generally absent. Also, the disease is commonly extrapulmonary and as such, chest x-ray may be unhelpful. These factors contribute in making the diagnosis of TB in patients on HD difficult and at times, the diagnosis is made only at post-mortem  .
We report our experience on TB in a group of patients on maintenance HD.
| Materials and Methods|| |
During the period between January 1986 and January 1993, 927 patients received maintenance HD at the dialysis unit of King Hussein Medical Center. There were 550 males and 377 females, their ages ranging from 15 to 74 years. The records of 11 patients who were diagnosed to have TB during this period were examined to determine the clinical presentation of their illness, the duration on HD before diagnosis of TB, the sites of involvement and the method of diagnosis of TB.
The specific investigations performed on these patients included radiological studies, smear and culture of sputum, urine, pleural, pericardial and ascitic fluids for acid fast bacilli, biopsies of lymph nodes and peritoneum as well as specimens from laparotomy which were available in two cases.
| Results|| |
Eleven patients out of 927 (1.2%) developed TB, the clinical features and results of special investigations of whom are given in [Table - 1]. There were seven females and four males and their ages ranged from 28 to 70 years. The basic renal disease in these patients was as follows: bilateral contracted kidneys in four, contracted kidneys with hypertension in three, chronic glomerulonephritis in two, horse-shoe kidney with hypertension and diabetic nephropathy in one patient each.
The duration on maintenance HD before the diagnosis of TB varied from 1 month to 24 months. In one patient, TB was detected at the time of commencement of HD. The majority of the study patients developed extra-pulmonary TB (81.8%) (3 TB lymphadenitis, 2 genito-urinary TB, 2 TB peritonitis, 2 TB pericarditis) and only two patients had pulmonary tuberculosis. The mode of presentation and method of diagnosis are shown in [Table - 1]. It may be noted that in all cases the diagnosis of TB was established unequivocally (by culture in 5 cases and histologically in 6 cases). All our patients were treated with a combination of two drugs: rifampicin 600 mg daily and isoniazid 300 mg daily. Pyrazinamide, 2 gm daily was added in three patients who had widespread TB. All patients additionally received pyridoxine 50 mg daily to prevent the development of peripheral neuropathy. The anti-tuberculous drugs were given in a single dose and on the day of dialysis the drugs were given at the end of the dialysis session. The treatment was continued for nine months. All the patients tolerated the treatment well and none developed any major side effects.
Six of the 11 patients survived for more than two years following diagnosis while five patients died (mortality rate 45.45%) [Table - 1]. However, none of these patients died due to a direct consequence of TB or its treatment.
| Discussion|| |
Despite earlier reports , suggesting no increase in the incidence of TB in dialysis patients, our results are in keeping with subsequent reports ,, that do indicate increased incidence. We observed the development of new active mycobacterial infection in 11 patients on maintenance HD at our center during an eight years period yielding a prevalence of 1.19% among 927 patients on HD. This figure is at least 100 times higher than the prevalence of active TB among the general population in some regions of Jordan (0.015%) (unpublished data from the Jordan Ministry of Health, 1993).
Extra-pulmonary presentation was found to be the most common feature among our study patients (81.8%) with tuberculous lymphadenitis being the most common presentation (27%). Predominance of pulmonary tuberculosis has also been reported by other investigators , . None of our patients were receiving steroids or cytotoxic drugs at the time TB was diagnosed and only one had associated diabetes mellitus.
Conflicting results have appeared concerning the use of purified protein derivative (PPD) skin test with some investigators , claiming a consistent negative result secondary to suppressed cellular immunity while others have reported a positive test in 62% of their cases  ; PPD was performed on six of our patients of whom two (33.3%) had positive test. Also, it is difficult to estimate the value of the skin test in areas where TB is endemic.
There have been differences of opinion regarding the use of antituberculous drugs, their dose and the duration of treatment. A combination of rifampicin and isoniazid is considered safe and all except two of our patients received only these drugs with good response and no side effects.
Previous reports suggest that the mortality in these patients is high; in some published series the overall mortality rate was 47.6% ,, . More recent reports however, have reported lesser mortality rates , . Although five of our patients died, none died due to TB or treatment-related side effects.
The results of the present study support the previously held view that TB occurs more frequently in patients on maintenance HD. We believe that in spite of impaired drug elimination and immune status, these patients can be safely managed with anti-tuberculous chemotherapy.
| References|| |
|1.||Wilson WE, Kirpatrick CH, Talmage DW. Suppression of immunologic responsiveness in uremia. Ann Inter Med 1965;62:1. |
|2.||Dobkin JF, Miller MH, Steigbigel NH. Septicemia in patients on chronic hemodialysis. Ann intern Med 1978;88:28-33. |
|3.||Newberry WM, anford JP. Defective cellular immunity in renal failure: depression of reactivity of lymphocytes to phytohemagglutinin by renal failure serum. J Clin Invest 1971;50:1262-71. |
|4.||Byron PR, Mallick NP, Taylor G. Immune potential in human uremia. 1. Relationship of glomerular filtration rate to depression of immune potential. J Clin Pathol 1976;29:765-9. |
|5.||Miller WT. Tuberculosis in the immunosuppressed patient. Semin Roentgenol 1979;14:249-55. |
|6.||Al-Tawil NG, Thewaini AJ. Study of the immunological status of patients with pulmonary tuberculosis. Scand J Immunol 1978;8:333-8. |
|7.||Bhatnagar R, Malaviya AN, Narayanan S, et al. Spectrum of immune response abnormalities in different clinical forms of tuberculosis. Am Rev Respir Dis 1977;115:207-12. |
|8.||Rutsky EA, Rostand SG, Mycobacteriosis in patients with chronic renal failure. Arch Intern Med 1980;140:57-61. |
|9.||Amedia C, Oettinger CW. Unusual presentation of tuberculosis in chronic hemodialysis patients. Clin Nephrol 1977;8:363-6. |
|10.||Sasaki S, Akiba T, Suenaga M, et al. Ten years'survey of dialysis-associated tuberculosis. Nephron 1979;24:141-5. |
|11.||Lundin AP, Adler AJ, Berlyne GM, Friedman EA. Tuberculosis in patients undergoing maintenance hemodialysis. Am J Med 1979;67:597-602. |
|12.||Andrew OT, Schoenfeld PY, Hopewell PC, Humphreys MH. Tuberculosis in patients with end stage renal disease. Am J Med 1980;68:59-65. |
|13.||Keane WF, Raij L. Infectious complications in maintenance dialysis patients, in Drukker, Parsons, Maher (eds). Replacement of renal function by dialysis. Dordecht, the Netherlands, Nihjoff 1978;621. |
|14.||Freeman R, New house CE, Lawton RL. Absence of tuberculosis in dialysis patients (Letter). JAMA 1975;233:1356. |
|15.||Papadimitriou M, Memmos D, Metaxas P. Tuberculosis in patients on regular haemodialysis. Nephron 1979;24:53-7. |
|16.||Pradhan RP, Katz LA, Nidus BD, Matalon R, Eisinger RP. Tuberculosis in dialyzed patients JAMA 1974;229:798-800. |
|17.||Fujino T. Miliary tuberculosis in patients under dialysis therapy. Kekkaku 1976;51:381-8. |
|18.||Adler AJ, Lundin AP, Zeig S, et al. Tuberculosis in maintenance haemodialysis (abstract). 11 International Congress of Nephrology, ontreal, Canada 1978;1-11. |
|19.||Al-Khader AA, Aswad S, Al-Sulaiman M, Babiker MAR. Prevalence of tuberculosis in the dialysis population of Saudi Arabia. Saudi Kidney Dis Transplant Bull 1990;l(3):155-7. |
|20.||Hussein MM, Babiker N, Roujouleh H. Tuberculosis in patients undergoing maintenance dialysis. Nephrol Dial Transplant 1990;5:584-7. |
Nephrology Department, King Hussein Medical Center, P.O. Box 960955, Amman
[Table - 1]