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| Year : 2009 | Volume
: 20
| Issue : 2 | Page : 254-259 |
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| Characteristics and outcomes of end-stage renal disease patients with active tuberculosis followed in intensive care units |
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Sevinc Sarinc Ulasli1, Gaye Ulubay1, Nevra Gullu Arslan1, Siren Sezer2, Sule Akcay1, Fusun Oner Eyuboglu1, Mehmet Haberal3
1 Department of Pulmonary Diseases, Baskent University, Faculty of Medicine, Ankara, Turkey
2 Department of Nephrology, Baskent University, Faculty of Medicine, Ankara, Turkey
3 Department of General Surgery, Baskent University, Faculty of Medicine, Ankara, Turkey
Click here for correspondence address and email
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 Abstract | | |
Tuberculosis (TB) remains a common problem in patients with chronic renal failure. In intensive care units, misdiagnosis or delayed diagnosis of TB is common. Therefore, a description of characteristics of active TB in patients with renal failure followed in intensive care units is important to reduce mortality and transmission of the disease. This study was performed to describe the characteristics of patients with renal failure admitted to the intensive care units and having active TB and evaluate predictive factors for in hospital mortality. The hospital records of 24 patients (11 women, 13 men) having ESRD and TB between 2001-2006 were reviewed. Clinical, radiological, and laboratory data on admission were recorded. Possible parameters contributing to in-hospital mortality were obtained from the medical records. In-hospital mortality rate was 66.6%. Factors associated with mortality were decreased partial pressure of oxygen and malnutrition. Fever was reported in 8 patients and hemoptysis was reported in 3 patients. Eight patients had consolidation on chest radiograph, while 4 had normal findings Seventeen patients had pulmonary involvement, and 11 had extra pulmonary involvement. The mortality rate in TB patients followed in intensive care units is high, with 3 factors contributing to in-hospital mortality. Clinicians should consider active TB in renal failure patients being followed in the intensive care unit, even when results of a chest radiograph are normal especially in patients with unexplained poor general health or respiratory failure. Keywords: Tuberculosis, End-stage renal disease, Intensive care units, Mortality, Risk factors
How to cite this article:
Ulasli SS, Ulubay G, Arslan NG, Sezer S, Akcay S, Eyuboglu FO, Haberal M. Characteristics and outcomes of end-stage renal disease patients with active tuberculosis followed in intensive care units. Saudi J Kidney Dis Transpl 2009;20:254-9 |
How to cite this URL:
Ulasli SS, Ulubay G, Arslan NG, Sezer S, Akcay S, Eyuboglu FO, Haberal M. Characteristics and outcomes of end-stage renal disease patients with active tuberculosis followed in intensive care units. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2013 May 25];20:254-9. Available from: http://www.sjkdt.org/text.asp?2009/20/2/254/45574 |
| Introduction | |  |
Despite the availability of effective chemotherapy, the incidence of tuberculosis (TB) and TB-related illnesses has increased since the 1970s and has become the leading cause of death due to an infection worldwide. [1],[2] Endstage renal disease (ESRD) is known to disrupt the cell-mediated immune response for killing intracellular organisms such as Mycobacterium tuberculosis. There is an increased risk (6.9- to 52.5-fold) of TB in patients with chronic renal failure undergoing dialysis as compared with the general population.
Early diagnosis of TB reduces mortality and morbidity rates and also reduces nosocomial transmission in patients with TB. [3] However, misdiagnosis or delayed diagnosis of TB as a cause of death is common in intensive respiratory care units. [4],[5],[6],[7],[8] Better descriptions of the disease's clinical features could improve diagnostic accuracy in this setting.
| Patients and Methods | | |
In this retrospective cohort study, we reviewed the hospital records of end-stage renal disease patients with microbiological diagnosis of active TB in our intensive care unit between 2001 and 2006. During that time, 24 patients (11 women, 13 men; aged 50 ± 16 years) were admitted to our intensive care unit for treatment of acute respiratory failure related to pulmonary TB or poor general health caused by TB. Microbiologic analysis included using direct light microscopy to reveal acid-fast bacilli in at least 1 Ziehl-Neelsen-stained respiratory tract secretion sample or positive cultures for the etiologic pathogen.
The following data were obtained from each patient's medical record: patient demographics (age and sex), presence of another comorbid disease or pre-existing risk factors for TB infection, chest radiograph patterns, symptoms, organ involvement of disease, results of blood gas analyses, duration of hospitalization, length of required mechanical ventilation in patients with respiratory failure, diagnostic methods for TB, administration of anti-TB therapy, and mortality. Respiratory failure was defined as requiring mechanical ventilation for at least 24 hours.
Radiographic patterns were classified as normal findings, consolidation, miliary pattern, pleural effusion, parenchymal cavity, fibrosis, and hilar or mediastinal lymphadenopathy. The number of lobes involved on the radiographs also was recorded. Septic shock was defined as sepsis with hypotension that, despite adequate fluid resuscitation, required vasopressor therapy. In addition, perfusion abnormalities included lactic acidosis, altered mental status, and acute lung injury in septic shock. [9]
Risk factors for TB infection included known contact with a person with active TB; abuse of either alcohol or drugs; diabetes mellitus requiring oral or parenteral hypoglycemic therapy; end-stage renal disease requiring dialysis; type of dialysis; presence of malnutrition (body mass index < 20 kg/m 2 ); gastrectomy; hematologic disease; drug-induced immunosuppression by corticosteroids, chemotherapy, or other immunomodulating drugs used to treat organ transplant patients; advanced age or collagenvascular disorders.
| Results | | |
Patient characteristics
The patients' characteristics are shown in [Table 1]. None of the patients had primary TB according to radiologic and clinical features. The patients had been receiving maintenance dialysis (mean renal failure duration, 64 months; hemodialysis/peritoneal dialysis, 23/1). Seven patients (29%) had received renal transplantation (mean transplant duration = 77 ± 64 months), with all organ recipients receiving standard immunosuppressive therapy including steroids, tacrolimus, and mycophenolate mofetil or cyclosporine (mean immunosuppressive therapy duration, 77 months).
Mean patient body temperature on admission was 37.9°C ± 0.9°C (range, 36.2°C-39.9°C). Fever was reported in 8 patients (33%; 4 patients did not have a fever before anti-TB treatment), and hemoptysis was reported in 3 patients (12%; [Table 2]). Seventeen patients had pulmonary involvement, and 11 had extra pulmonary involvement (lymph node, n= 1; lymph node plus central nervous system, n= 2; pleura, n= 3; small intestine, n= 1; knee, n= 1; kidney, n= 2; and vertebrae and central nervous system, n= 1). Four patients had both pulmonary and extra pulmonary involvement.
Eight patients (36%) had consolidation on chest radiograph, while 4 (18%) had a miliary pattern, 4 (18%) had pleural effusion, 1 (4.5%) had cavitation, and 4 (18%) had normal findings. Bedside flexible bronchoscopic procedures (endobronchial biopsy in 3, bronchial lavage in 10) were performed in 11 patients with abnormal chest radiograph findings.
TB was diagnosed by direct light microscopy examination of respiratory tract secretion sample (n= 17) including sputum or bronchial lavage samples, bacilli in the gastric fluid (n= 1), positive sputum or bronchial lavage cultures (n= 5), or positive bone marrow polymerized chain reaction (n= 1). TB was diagnosed on biopsy specimens in 13 patients, with caseating granulomas in 7 of those. Treatment in all 24 patients included either oral or parenteral administration of 3 or more first-line anti-TB drugs: isoniazid, rifampin, pyrazinamide, and ethambutol. One patient received steroids (1 mg/kg/day) because of the presence of TB meningitis. None of the patients received secondline anti-TB drugs. One patient receiving isoniazid (INH) had a seizure as an adverse effect.
Mortality
Sixteen patients (66%) who required invasive mechanical ventilation for respiratory failure died following admission to the ICU at a mean of 25 ± 14 days. Partial oxygen pressure in arterial blood samples was 45 ± 8 mmHg. Most patients (75%) had another comorbid disease such as systemic hypertension (n= 13), congestive heart failure (n= 1), malignancy (n= 1), both systemic hypertension and diabetes mellitus (n= 3). Six of 16 patients (40%) who died had consolidation on chest radiographs, 3 (20%) had a miliary pattern, 3 (20%) had pleural effusions, 2 (13.3%) had fibrosis, and 2 (13.3%) had normal chest radiographs. Ventilator associated pneumonia from other microorganisms occurred in 6 patients [Table 3].
Univariate analyses identified the risk factors for TB that were significantly associated with mortality [Table 4]. The most significant among these were malnutrition, serum creatinine level, and partial arterial pressure of oxygen. Disease presentation and treatment did not correlate with mortality. Co infection with other microorganisms also was not a risk factor for mortality.
| Discussion | | |
Sixteen TB patients died between 2 and 180 days after admission to the ICU (mortality rate, 66.6%). Univariate analyses showed that, malnutrition and respiratory failure was independently associated with patient in-hospital mortality. The association between respiratory failure and a higher mortality rate agrees with prior studies that show high mortality rates (47%-80%) for TB patients who required me chanical ventilation. [2],[10]
According to World Health Organization records, the number of TB patients in Turkey in 2000 was 18 038 out of a total of 66 668 000 persons with an incidence of 0.0027%. [11] If TB is not endemic in a community, exposure of older persons and children to Mycobacterium bacilli may lead to primary TB. Otherwise, in endemic areas like Turkey, reactivation is the main mechanism of infection in adults owing to the high exposure risk. [12]
Pulmonary TB characterized by lymphadenopathy, pleural effusions, and zone infiltrates in the lower lung or mid lung on chest radiograph represent a primary disease from a recently acquired infection, whereas upper lobe infiltrates and cavities represent secondary or reactivation of the disease. [13],[14],[15] In ESRD patients the clinical features of TB are usually atypical, mimicking the primary disease with lower lung or mid lung zone infiltrates without cavities. [15]
All of our patients were older than 18 years. Twelve of our patients had fibrosis or hilar or apical calcified lesions, indicating primary infection in the past; 11 of them had extra pulmonary TB. Thus, reactivation of TB was the most common form seen in our study.
Previous studies show that the mortality is increased when TB coexists with chronic sicknesses such as infection with HIV, diabetes mellitus, chronic heart failure, rheumatoid arthritis (low dose prednisone therapy), sarcoidosis (prior prednisone therapy), alcohol abuse, COPD, malignancy, chronic pancreatitis, and solid-organ transplantation. [2],[13],[16],[17],[18],[19]
It is well known that patients with ESRD and those on chronic dialysis have at least a 10- to 40-fold greater risk of developing TB compared with persons in the general population [15],[20] and use of bio-incompatible membranes may contribute by causing polymorphic nuclear dysfunction, such as chemotaxis, adherence, and phagocytosis. [15]
Extra pulmonary involvement of mycobacterial infections is more frequent than isolated pulmonary involvement in ESRD patients [15] possibly due to the impaired cellular immunity in such patients. The incidence of extra pulmonary involvement in ESRD patient's ranges from 40% to 80% in recent studies. [21],[22],[23],[24] Consistent with those studies, 45.8% of our patients had extrapulmonary involvement. Multi drug-resistant TB was not present in our patient population in contrast to TB mortality studies that involved younger and primarily outpatient populations. [25],[26] Our patient population did not have a past medical history of active TB or medical treatment for TB, which could explain this difference.
Malnourished patients are particularly vulnerable to pulmonary infection. Starvation significantly depresses the phagocytic ability of pulmonary alveolar macrophages, which play important roles in the local cellular defenses of the lung. [27] In our study, 12 patients were malnourished, 13 had hypoalbuminemia, and 9 had general debilitation due to co morbidities. Univariate analysis also suggested an association between malnutrition and TB related mortality, nevertheless, it is unclear whether malnutrition was a cause or an effect.
In conclusion, we found a high mortality rate in TB patients followed in the intensive care units and identified respiratory failure requiring mechanical ventilation, and malnutrition, as risk factors for mortality. To reduce delayed diagnosis and mortality, TB should be considered in ESRD patients admitted to the ICU for unexplained or non responding infections.
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Correspondence Address:
Sevinc Sarinc Ulasli
Department of Pulmonary Diseases, Baskent University, Fevzi Cakmak Cad, 5 sok, No 48, Postal Code 06490, Besevler, Ankara
Turkey
PMID: 19237814
[Table 1], [Table 2], [Table 3], [Table 4] |
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