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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2014  |  Volume : 25  |  Issue : 2  |  Page : 428-431
Pulmonary tuberculosis in patients with chronic renal failure

1 Infectious Disease Research Center, Golestan University of Medical Sciences, Golestan, Iran
2 Department of Psychiatry, Tehran University of Medical Sciences, Tehran, Iran
3 Department of Microbiology, Golestan University of Medical Sciences, Golestan, Iran
4 Department of Epidemiology, Tehran University of Medical Sciences, Tehran, Iran
5 Department of Social Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
6 Department of Anesthesiology, Golestan University of Medical Sciences, Golestan, Iran

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Date of Web Publication11-Mar-2014

How to cite this article:
Golsha R, Kashani L, Okhly M, Keshtkar AA, Golshah E, Momtaz NS. Pulmonary tuberculosis in patients with chronic renal failure. Saudi J Kidney Dis Transpl 2014;25:428-31

How to cite this URL:
Golsha R, Kashani L, Okhly M, Keshtkar AA, Golshah E, Momtaz NS. Pulmonary tuberculosis in patients with chronic renal failure. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2020 Jun 1];25:428-31. Available from: http://www.sjkdt.org/text.asp?2014/25/2/428/128611
To the Editor,

Mycobacterium tuberculosis continues to be a major health problem in the world, especially in the developing countries. According to the World Health Organization (WHO) report in 2007, there were 8.8 million new cases of tuberculosis (TB) in 2004, which amounts to 136/100,000 population; of them, 6.1 million lost their lives due to the disease, yielding a mortality rate of 24 per 100,000 population. [1] The incidence of active TB in developed coun­tries has been reported to be 10.4/100,000 population. [2]

In Iran, the incidence and prevalence of TB differs in different areas. According to the Disease Management Center, the incidence of TB in Iran, from 1999 to 2003, was 7.47/100,000 population, while during the same period, the incidence was 22.4/100,000 population in the Golestan province (Iran). Regarding the inci­dence of TB, the Golestan province is second only to the Sistan and Blochestan provinces. [3]

In Saudi Arabia, the incidence of TB in the general population, from 1987 to 2002, was between 10.2 and 30.5 per 100,000 popula­tion. [1] Kidney transplant recipients and hemo­dialysis (HD) patients are at a high risk for developing TB. The incidence of TB in these groups is more than 24%. [4]

This retrospective study was conducted to assess the prevalence of pulmonary TB in patients with end-stage renal disease (ESRD) in the 5-Azar Hospital, Northeast of Iran, from 1993 to 2003; the data were compared with the prevalence of pulmonary TB in the general population.

We evaluated the medical files of 695 ESRD patients at the referral hospital affiliated to the Golestan University of Medical Sciences bet­ween 1993 and 2003. We included patients over 14 years old and those who were on maintenance HD for longer than three months.

Pulmonary TB was defined according to the WHO guidelines: Two or more acid-fast ba­cilli (AFB)-positive sputum smears or one AFB-positive smear and TB-related radiologic changes or AFB-positive sputum culture. [1] Smear-negative pulmonary TB comprised of patients who did not meet the above-men­tioned criteria.

The white blood cell (WBC) counts and he­moglobin (Hb) levels were checked in all study patients at the beginning of the study. The following groups of patients were exclu­ded from our study: Those in whom primary diagnosis of TB was ruled out, those who died without a definite diagnosis and those who were referred to other therapeutic centers.

Information regarding age, gender, date of contracting TB, clinical signs, laboratory data, X-rays and history of previous smear-positive pulmonary TB were collected from the pa­tients' files and entered in the checklists. We used epidemiology collaboration info version 6 and SPSS version 15 software to analyze the data. The odds ratio was calculated. The confi­dence interval and P-value were considered as 95% and 0.05, respectively.

This study was conducted on 695 ESRD patients over a 10-year period (1993-2003). Fourteen of these patients were diagnosed to have pulmonary TB, including six males (42.9%) and eight females (57.1%). The mean age was 52.3 ± 19 years (20-86 years), with the majority aged between 41 and 50 years (35.7%). Nine patients (64.2%) were diag­nosed based on a positive smear for AFB while five patients (35.7%) were diagnosed based on clinical and radiological evidence as well as response to treatment.

Four of the 14 patients (28.5%) had a pre­vious history of pulmonary TB. Co-existing pulmonary and extra-pulmonary TB was ob­served in four patients [Table 1]. The frequency distribution of radiologic lesions among the patients with pulmonary TB as well as their clinical symptoms is shown in [Table 2].
Table 1: Demographic data of patients with endstage renal disease diagnosed as having tuberculosis.

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Table 2: Clinical presentation and radiologic findings in patients with end-stage renal disease diagnosed to have tuberculosis.

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In this retrospective descriptive study, we found that 14 patients had pulmonary TB (in­cidence = 2.01%). The relative incidence of smear-positive and smear-negative pulmonary TB in the study patients was 0.013 and 0.115, respectively, which is higher than in the general population of the Golestan province. This means that the risk of pulmonary TB in ESRD patients is 43.3-times higher than in the general population of the Golestan province [Table 3].
Table 3: Comparison of the incidence of tuberculosis in the general population and among patients on dialysis.

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Dialysis patients are at a greater risk for de­veloping advanced active TB after primary infection as well as reactivation of old TB or activation of dormant infection. [2],[4],[5] Risk fac­tors such as impaired cellular immunity, da­maged mucus membranes and skin, malnutri­tion, acidosis, vitamin D deficiency, hyper­parathyroidism, low socioeconomic status, living in crowded conditions and some eth­nicities are possible reasons for the increased risk. [6],[7]

Worldwide, the reported prevalence of TB among HD patients has been reported to be 5-25%, and the risk of active TB in this group is 8.9-52.5 times more than in the general po­pulation. [8],[9],[10],[11],[12] In the study by Sen et al in Turkey (2001-2006), the prevalence of TB among 343 HD patients was 5.2%, which was 186 times higher than in the general population (27.9/ 100,000). [6]

In another study from Turkey, the reported prevalence of TB in HD patients was 10to40 times higher than in the general population. [13] Similarly, in a study from Greece (20 07), the risk of TB in HD patients was 67.2 times greater than in the general population. [9]

The difference between our results and most of the above-mentioned studies can be due to the higher prevalence of TB in the Golestan province than in the whole country (Iran). According to the Golestan Health Center Sta­tistics and Disease Management Center, the incidence of TB in the province during 1993-2003 was 22.4/100,000 population, while it was 7.47/100,000 in the whole country (Iran). [3]

In our study, eight patients with TB were female (57.1%) and six patients were male (42.9%). Quantrill et al reported a female to male ratio of 1:1 among 24 cases of TB. [14] In our study also there was no statistically sig­nificant sex difference in the prevalence of TB.

The most common clinical symptoms were cough (28.57%), dyspnea (28.57%), altered sensorium (21.42%) and hemoptysis (7.14%). In the study of Abdelrahman et al, there were no cases with hemoptysis, and the most com­mon symptoms were anorexia, weight loss and low-grade fever. [5] Thus, in patients with ESRD, active TB may present with atypical signs and symptoms.

In conclusion, ESRD patients are more prone to pulmonary TB than the general population. Thus, regular screening for pulmonary TB is required in these patients, especially in coun­tries where TB is endemic. Besides, every pulmonary symptom should raise the suspicion of pulmonary TB in ESRD patients.

   Limitations Top

There were some limitations in our study, which include: Under-reporting of pulmonary TB in the general population and some pa­tients with pulmonary TB undergoing dialysis outside the province thus being missed for analysis.

   Acknowledgment Top

The authors would like to express their gratitude to all 5-Azar Hospital staff, especially those who worked in the dialysis ward, for helping them in this study.

   References Top

1.World Health Organization, Global tubercu-losis control: Surveillance, planning, financing. WHO Report 2007, WHO, Geneva (2007) (WHO/HTM/TB 2007.376).  Back to cited text no. 1
2.Kayabasi H, Sit D, Kadiroglu AK, Kara IH, Yilmaz ME. The prevalence and the charac-teristics of tuberculosis patients undergoing chronic dialysis treatment: Experience of a dialysis center in Southeast Turkey. Ren Fail 2008;30:513-9.  Back to cited text no. 2
3.Available from: http://www.cdc.hbi.ir/healthtopic/world_global_tb.html.   Back to cited text no. 3
4.Moore DA, Lightstone L, Javid B, Friedland JS. High rates of tuberculosis in end-stage renal failure: The impact of international migration. Emerg Infect Dis 2002;8:77-8.  Back to cited text no. 4
5.Abdelrahman M, Sinha AK, Karkar A. Tuber-culosis in end-stage renal disease patients on hemodialysis. Hemodial Int 2006;10:360-4.  Back to cited text no. 5
6.Sen N, Turunc T, Karatasli M, Sezer S, Demiroglu YZ, Oner Eyuboglu F. Tubercu-losis in patients with end-stage renal disease undergoing dialysis in an endemic region of Turkey. Transplant Proc 2008;40:81-4.  Back to cited text no. 6
7.Erkoc R, Dogan E, Sayarlioglu H, et al. Tuber-culosis in dialysis patients, single centre expe-rience from an endemic area. Int J Clin Pract 2004;58:1115-7.  Back to cited text no. 7
8.AL Shohaib S. Tuberculosis in chronic renal failure in Jeddah. J Infect 2000;40:150-3.  Back to cited text no. 8
9.Christopoulos AI, Diamantopoulos AA, Dimopoulos PA, Gumenos DS, Barbalias GA. Risk of tuberculosis in dialysis patients: association of tuberculin and 2,4- dinitrochlorobenzene reactivity with risk of tuberculosis. Int Urol Nephrol 2006;38:745-51.  Back to cited text no. 9
10.Hussein MM, Mooij JM, Roujouleh H. Tuberculosis and chronic renal disease. Semin Dial 2003;16:38-44.  Back to cited text no. 10
11.Aladren MJ, Vives PJ, Celorrio JM. Diagnosis and prevention of tuberculosis in hemodialysis patients. A new old problem? Nefrologia 2004; 24:253-60.  Back to cited text no. 11
12.Klote MM, Agodoa LY, Abbott KC. Risk factors for Mycobacterium tuberculosis in US chronic dialysis patients. Nephrol Dial Transplant 2006;21:3287-92.  Back to cited text no. 12
13.Ulasli SS, Ulubay G, Arslan NG, et al. charac-teristics and outcomes of end - stage renal disease patients with active tuberculosis fol-lowed in intensive care units. Saudi J Kidney Dis Transpl 2009;20:254-9.  Back to cited text no. 13
[PUBMED]  Medknow Journal  
14.Quantrill SJ, Woodhead MA, Bell CE, Hardy CC, Hutchison AJ, Gokal R. Side effects of antituberculosis drug treatment in patients with chronic renal failure. Eur Respir J 2002;20: 440-3.  Back to cited text no. 14

Correspondence Address:
Roghieh Golsha
Infectious Disease Research Center, Golestan University of Medical Sciences, Golestan
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DOI: 10.4103/1319-2442.128611

PMID: 24626021

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