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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2010  |  Volume : 21  |  Issue : 1  |  Page : 164-167
Prevalence of tuberculosis in hemodialysis patients

Service of Nephrology, Dialysis and Kidney Transplantation, Military Hospital Mohammed V, Rabat, Morocco

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Date of Web Publication8-Jan-2010

How to cite this article:
El Kabbaj D, Bahadi A, Oualim Z. Prevalence of tuberculosis in hemodialysis patients. Saudi J Kidney Dis Transpl 2010;21:164-7

How to cite this URL:
El Kabbaj D, Bahadi A, Oualim Z. Prevalence of tuberculosis in hemodialysis patients. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2021 Jul 27];21:164-7. Available from: https://www.sjkdt.org/text.asp?2010/21/1/164/58798

   Introduction Top

Patients undergoing chronic dialysis have a high incidence of serious infection due to im­paired host defence mechanisms which may be related to their impaired cell-mediated and hu­moral immunity. [1],[2],[3],[4] The presentation of tuber­culosis (TB) in uremic patients is often quite unusual and insidious. Moreover, the diagnosis and management of TB in such patients pro­vide the treating physician with many special challenges. Depressed cellular immunity has been associated with infections due to Myco­bacterium tuberculosis. [5],[6],[7]

We here report frequency of TB in our hemo­dialysis cohort of 340 patients.

   Methods Top

340 patients undergoing chronic maintenance hemodialysis between 1999 and 2008 were eva­luated retrospectively for the presence of TB. Total of 41 cases were identified. All patients were undergoing 3 sessions weekly for 4 hours using cellulose membranes. The diagnosis of tuberculosis was suspected with symptoms of fever, weight loss, hilar or generalized lympha­denopathy or persistent abdominal symptoms. Diagnostic evaluation included acid fast bacilli staining by ZN staining of sputum, gastric aspi­rate, chest x-ray and C-reactive protein. Other specific investigations included 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.

Our recommended therapeutic regimen inclu­ded 12 months of Rifampicin (R) and Isoniazid (H); and addionally 2 months of Pyrazinamide (Z), Ethambutol (E) or Steptomycin (S) (among first patients a treatment by Streptomycin for 2 months was prescribed when we found the ba­cillus of Koch in the bronchial aspirate). With half dose of H (2.5 mg/kg/d) half dose of Z (15 mg/kg/d), adapted dose of E (7.5 g/kg/d), S in the dose of 15 mg/kg/48h and full dose of R (10 mg/kg/d).

   Results Top

41 cases of tuberculosis were diagnosed du­ring the study period with a frequency of 6%. The average age of this population is 43 years (23-67 years). We note a male prevalence (58%); and majority were from low socioeconomic status. The mean interval between the onset of HD and the time of diagnosis was about 39 months, mainly extra- pulmonary TB was diag­nosed in 23 cases (56%): 7(17%) cases with lymph nodes involvement, 4 (9.7%) cases peri­toneal TB, 4 (9.7%) cases of spondylodiscitis localization with histological confirmation with the biopsy of the spondylodiscitis scan guided, one (2%) patient with parathyroid localization incidentally discovered on histopathology (epi­thelioid granuloma and caseous necrosis) of a parathyroid adenoma operated for, one (2%) axiliary cold abscess with cutaneous fistula con­firmed on histology [Table 1].

Six cases (14%) had multisystem involvement, with 2 (4.8%) cases of lymph node and peri­toneal TB, 2 (4.8%) cases of pericardial and pleural TB, a case (2%) of a osteomyelitis and pulmonary TB and a case (2%) where patient was operated for renal cell carcinoma with me­tastasis to the spleen and lymph nodes and found to have TB instead on histopathology of the resected renal mass [Table 1].

For the thoracic localizations 18 cases (41%), we report 8 (19.5%) cases of pulmonary loca­lization including 5 (12%) cases with positive acid fast bacilli in sputum, 7 (17%) cases of pleural localization with lymphocytic, exudate and pleural effusions and histological confir­mation in 2 cases, 2 cases of miliary tubercu­losis with one death. one patient with pericar­dial localization [Table 1].

Relapse of tuberculosis occurred in 6 patients [Table 2].

The clinical presentation included fever and malaise in 80% of the patients. The other clini­cal features at presentation were the peripheral lymph nodes enlargement, ascites, cough, dysp­nea, the spondylodiscitis pains and chest pain.

Confirmation of TB was done in 25 cases (60%), 21 (51%) cases of histological diagno­sis and 4 (9%) cases of bacteriological diagno­sis [Table 3], all the other cases had a strong clinical, radiological suspicion and good clini­cal response to anti-tuberculous drugs.

The duration of our treatment was 12 months. Various therapeutic protocols for first two months and then ten months were as follows:

RHZ RH n= 20 patients (48%).

ERHZ RH n= 14 patients (34%).

SRHZ/RH n= 4 patients (9%).

SERHZ/RH n= 3 patients (7%).

The anti-tuberculous drugs were given in a single dose 2 hours before meals and 6 hours earlier than the dialysis session.

Six patients presented with reversible neuro­logical symptoms mainly confusion and required adjustment of Isoniazid dose. One patient pre­sented with reversible vision abnormalities and required discontinuation of Ethambutol and 2 other patients developed deafness with Strep­tomycin. Monitoring of I levels revealed an ave­rage concentration of 3.13 ΅g/mL (0-13.5), the adjusted dose of I was therefore 2.75 mg/kg (0.63-17.68 mg/kg).

Six (14%) patients died. One patient with pa­rathyroid tuberculosis died 4 months after diag­noses due to unknown cause and the other 5 patients died due to pulmonary complications of milliary TB. One patient with pulmonary TB relapsed after one year.

   Discussion Top

The frequency of tuberculosis among hemo­dialysis patients is higher than in the general population, it varies between 0.4 to 18%; the highest rates are noted in the developing coun­tries. Several factors have been proposed in­cluding, lower socioeconomic status, iron over­load and hemodialysis procedure itself. [4] Him­melfarb and Hakim found that granulocyte pha­gocytic activity, natural killer cell function and lymphocyte interleukin-2 (IL2) receptor densi­ties may be impaired to a greater extent when dialysis is performed using unsubstituted cellu­lose membranes than when using synthetic membranes. [8] TB in majority of hemodialysis patients is usually diagnosed in the first 6 months of starting hemodialysis. [9],[10],[11] In our series, 24% of the patients developed tuberculosis within this time. This precocity of tuberculosis affec­ted can be related to the probable reactivation of old tuberculosis. [12]

The diagnostic difficulties commonly are the absence of symptoms, the often missing bacte­riological proof, 16 (39%) cases in our series, and the higher frequency of the extra-pulmo­nary presentation. [13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23] Lymphadenopathy was the commonest (17%) extrapulmonary presen­tation in our series, the similar to the series by Zahiri. [14] The reasons for increase in the fre­quency of extrapulmonary TB are not clear.

However, the higher incidence of extrapulmo­nary TB in dialysis patients may be the cause for delay in diagnosis as suggested by Andrew et al. [18]

Initiation of anti-TB therapy empirically is therefore not uncommon especially in hemo­dialysis patients. [16],[17]

The diagnostic confirmation from lymph nodes was 100% in our cases only 33% from pleural localization, bacillus was found in sputum only in 12% of the cases [Table 3], similar to others. [11],[12]

For the therapeutic incidents, apart from the neuropsychiatric complications which are fa­voured by the impaired renal function, the side effects do not seem more frequent in the he­modialysis patients and are reversible in the majority of cases after the discontinuation of the treatment.

Concerning the duration of treatment the majority of the authors agree over a prolonged course at the hemodialysis patents. It is 14 month on average.

Death as a result of TB in hemodialysis patients varies in different series from 12 -75% [Table 4]. [17],[18],[19],[20] Delay in the diagnosis is usually the cause of mortality in majority.

Higher mortality was reported in the early case series and more recent studies show im­provement. [21],[22],[23] In our patients with the high index of suspicion and application of diagnos­tic procedures resulting in early diagnosis and empirical therapy resulted in mortality of only 14 %.

In conclusion, the frequency of tuberculosis in our HD patients was similar to reported by others. Early diagnostic and therapeutic consi­derations will help in improving the outcome of TB among HD patients.

   References Top

1.Wilson WE, Kirpatrick CH, Talmage DW. Sup­pression of immunologic responsiveness in ure­mia. Ann Intern Med 1965;62:1.  Back to cited text no. 1      
2.Dobkin JF, Miller MH, Steigbigel NH. Septicemia in patients on chronic hemodialysis. Ann InternMed 1978;88:28-33.  Back to cited text no. 2      
3.Newberry WM, Anford JP. Defective cellular immunity in renal failure: depression of reactivity of lymphocytes to phytohemaglutinin by renal failure serum. J Clin Invest 1971;50:1262-71.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
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.  Back to cited text no. 4      
5.Miller WT. Tuberculosis in the immunosuppressed patient. Semin Roentgenol 1979;14:249-55.  Back to cited text no. 5  [PUBMED]    
6.Al-Tawil NG, Thewaini AJ. Study of the immu­nological status of patients with pulmonary tuber­culosis. Scand J Immunol 1978;8:333-8.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]  
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.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]  
8.Himmelfarb J, Hakim RM. Biocompatibility and risk of infection in hemodialysis patients. Nephrol Dial Transplant 1994;9[Suppl2]:138-44.  Back to cited text no. 8      
9.Sasaki S, Akiba T, Suenaga M, et al. Ten years survey of dialysis-associated tuberculosis. Nephron 1979;24:141-5.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]  
10.Hussein MM, Bakir N, Boujouleh H. Tubercu­losis in patients undergoing maintenance dialysis. Nephrol Dial Transplant 1990;5:584-7.  Back to cited text no. 10      
11.Hachicha J, Chaabouni MN, Maalej S, Jarraya A. Tuberculosis in chronic hemodialysis patients. Nephrologie 1986;5:211-2.  Back to cited text no. 11      
12.Goldman M, Vanherweghem JL. Bacterial infec­tions among patients in iterative hemodialysis: epidemiologic and physiopathological aspects: Nephrological actuality Necker Hospital. Paris Flammarion Ed 1989; 327-42.  Back to cited text no. 12      
13.Abdelrahman M, Sinha AK, Karkar A. Tubercu­losis in end-stage renal disease patients on hemo­dialysis. Hemodial Int 2006;10(4):360-4.  Back to cited text no. 13      
14.Zahiri K, Ramdani B, Hachim K, et al. Tuber­culosis in hemodialysis. Nephrologie 1997;18: 303-6  Back to cited text no. 14  [PUBMED]  [FULLTEXT]  
15.Langlois S, Barre P, Martinez L (eds). Various modes of presentation of tuberculosis in hemo­dialysis patients. Union Med Can 1983;112:1084-­7.  Back to cited text no. 15      
16.Lundin AP, Adler AJ, Berlyne GM, Friedman EA. Tuberculosis in patients undergoing mainte­nance hemodialysis. Am J Med 1979;67:597-602  Back to cited text no. 16  [PUBMED]  [FULLTEXT]  
17.Andrew OT, Schoenfeld PY, Hopewell PC, Humphreys MH. Tuberculosis in patients with end-stage renal disease. Am J Med 1980;68:59-­65.  Back to cited text no. 17  [PUBMED]  [FULLTEXT]  
18.Pradhan RP, Katz LA, Nidus BD, Matalon R, Eisinger RP. Tuberculosis in dialyzed patients. JAMA 1974;229:798-800.  Back to cited text no. 18  [PUBMED]  [FULLTEXT]  
19.Amedia C, Oettinger CW. Unusual presentation of tuberculosis in chronic hemodialysis patients. Clin Nephrol 1977;8:363-6.  Back to cited text no. 19  [PUBMED]  [FULLTEXT]  
20.Cengiz K. Should tuberculosis prophylaxis be given for the chronically dialyzed patients. Nephron 2000;86:411-3.  Back to cited text no. 20  [PUBMED]  [FULLTEXT]  
21.Al-Homrany M. Successful therapy of Tubercu­losis in hemodialysis patients. Am J Nephrol 1997;17:32-5.  Back to cited text no. 21  [PUBMED]  [FULLTEXT]  
22.Malik GH, Al-Mohaya SA, Al-Harbi AS, et al. Spectrum of Tuberculosis in Dialysis Patients in Saudi Arabia. Saudi J Kidney Dis Transpl 2003; 14:145-52.  Back to cited text no. 22  [PUBMED]  Medknow Journal  
23.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.  Back to cited text no. 23  [PUBMED]  Medknow Journal  

Correspondence Address:
Driss El Kabbaj
Service of Nephrology, Dialysis and Kidney Transplantation, Military Hospital Mohammed V, Rabat
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  [Table 1], [Table 2], [Table 3], [Table 4]


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