Saudi Journal of Kidney Diseases and Transplantation

RENAL DATA FROM THE ARAB WORLD
Year
: 2016  |  Volume : 27  |  Issue : 5  |  Page : 992--996

Prevalence and presentation of tuberculosis among hemodialysis patients in Khartoum, Sudan


Amin S. I. Banaga1, Nihad K Siddiq2, Randa T Alsayed2, Rasha Babiker3, Khalifa Elmusharaf4,  
1 Department of Medicine and Nephrology, University of Medical Sciences and Technology; Department of Hemodialysis, Academy Charity Teaching Hospital, Khartoum, Sudan
2 Department of Nephrology, Academy Charity Teaching Hospital, Khartoum, Sudan
3 Department of Basic Sciences, Faculty of Medicine, University of Medical Sciences and Technology, Khartoum, Sudan
4 Department of Public Health, Graduate Entry Medical School, University of Limerick, Limerick, Ireland

Correspondence Address:
Amin S. I. Banaga
Department of Medicine and Nephrology, University of Medical Sciences and Technology, P. O. Box. 12810, Khartoum
Sudan

Abstract

Tuberculosis (TB) is a major health problem in the developing countries. There are limited data about the prevalence of TB patients on maintenance hemodialysis (HD) in Sudan. The aim of this study is to identify the prevalence and presentation of TB among Sudanese maintenance HD patients. This is a hospital-based descriptive study. The participants of the study are all HD patients distributed in 13 HD centers in Khartoum and Khartoum North Provinces in Sudan. All patients attended the HD centers from November 1, 2014 to February 1, 2015, were interviewed by a questionnaire focused on personal and clinical data. Those who were diagnosed as having active TB were studied regarding their clinical presentation, presence of comorbidities, site of TB, and methods used on diagnosis. The total number of HD patients during the study period was 1328 patients. We found 19 patients who already diagnosed and treated for TB infection. The prevalence rate of TB among HD patients is 1.4%. The mean age of patient was 44.53±8.69 years, 89.5% of them were males. The majority of them have comorbidities: 31.6%% have hypertension and 21.1% have diabetes. Extrapulmonary TB was the major presentation (57.9%) mainly tuberculous lymphadenitis (26.3%). The pulmonary presentation was found to be 42.1%. The diagnosis of TB was supported by microbiological evidence of alcohol acid-fast Bacilli present in sputum smear (21%), histological diagnosis (31.6%), polymerase chain reaction (21%), and imaging in (26.3%). Patients on maintenance HD are at an increased risk of TB and diagnosis of TB among HD patients need a high index of suspicion. There is a great need for establishing a screening scheme for TB among HD patients and further epidemiological studies are needed to fully evaluate this problem.



How to cite this article:
Banaga AS, Siddiq NK, Alsayed RT, Babiker R, Elmusharaf K. Prevalence and presentation of tuberculosis among hemodialysis patients in Khartoum, Sudan.Saudi J Kidney Dis Transpl 2016;27:992-996


How to cite this URL:
Banaga AS, Siddiq NK, Alsayed RT, Babiker R, Elmusharaf K. Prevalence and presentation of tuberculosis among hemodialysis patients in Khartoum, Sudan. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2021 Oct 22 ];27:992-996
Available from: https://www.sjkdt.org/text.asp?2016/27/5/992/190873


Full Text

 Introduction



The World Health Organization (WHO) 2014 Report estimated that the rate of tuberculosis (TB) in Africa was reached 263-341/100,000 population. [1] In the year 2013, the WHO reported that the notification rate of TB in Sudan was 108 cases per 100,000 population. [2]

Many studies pointed out the increase rate of TB among patients with end-stage renal failure (ESRF) in comparison with the general population. A study conducted among hemodialysis (HD) patients migrated to the United Kingdom from TB endemic countries reported a TB rate of 1187 cases per 100,000 per year. [3] In other study, the incidence rate of TB among HD patients was 3.1%. [4] Further studies found the rate of TB among dialysis patients was ranging from 12 to 26 times more than in the general population. [5],[6] The reason behind the increase rate of TB among ESRF patients is related to the change in immune response which associated with uremic toxins and exacerbated by dialysis. [7]

There is limited data about the rate of TB cases among HD patients in Sudan. However, there was study reported that 5.4% of patients in peritoneal dialysis have active TB. [8] The aim of this study is to identify the prevalence and presentation of TB among HD patients in Khartoum, Sudan.

 Materials and Methods



This study is a hospital-based descriptive study. The participants of the study are all HD patients distributed in 13 HD centers in Khartoum and Khartoum North Provinces in Sudan. All patients attended the HD centers from November 1, 2014, to February 1, 2015, were interviewed by questionnaire focused on personal and clinical data. Those who were diagnosed as having active TB were studied further. Their medical files were reviewed to identify the clinical presentation, presence of comorbidities, site of TB, and methods used on diagnosis.

The research was approved by Ethics and Research Comities in the Ministry of Health and local hospitals. An informed consent was obtained from each patient participated in the study.

 Statistical Analysis



Data were analyzed using the Software Package for the Social Sciences (SPSS) version 21 (IBM Corp., 2012). IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY, USA. Results were presented in number, percent, mean, and standard deviation.

 Results



The characteristics of the study population are shown in [Table 1]. The total number of HD patients was 1328 patients. We found 19 patients who were already diagnosed and being treated for TB infection. The prevalence rate of TB among HD patients is 1.4%. The mean age of patient was 44.53 ± 8.69 years, 89.5% of them were males.{Table 1}

The majority of the study population had comorbidities, 31.6% have primary hypertension and 21.1% have diabetes mellitus. Extrapulmonary TB was the major presentation (57.9%) [Table 2]. The pulmonary presentation was found to be 42.1%. The diagnosis of TB was supported by microbiological evidence of alcohol acid fast Bacilli (AAFB) in sputum smear (21%), histological diagnosis (31.6%), polymerase chain reaction (PCR) (21%), and imaging in (26.3%) [Table 3].{Table 2}{Table 3}

 Discussion



In the current study, we found that the prevalence of TB among HD patients is 1.4%, this is considered to be 14 more times than TB in the general population in Sudan according to the WHO 2013 statistics. [2] Several studies reported the increased prevalence of TB among dialysis patients. [3],[4],[7] The prevalence of TB among dialysis patients range from 12 to 26 more times in the general population. [5],[6]

In this study, we noticed that the mean age of our patients is younger than other studies where the mean age of patients is usually above 50-year-old. [4],[5] However, a similar study conducted in Sudan among peritoneal dialysis patients found that the mean age of TB patients was 37-year-old. [8] This is most likely due to the fact that ESRF in Sudan is predominantly affecting the young population. [9]

In the current study, the mean duration of HD among TB patients was about 40 months. This agrees with other study conducted in the United Kingdom among HD patients migrated from TB endemic areas which reported that the mean duration of dialysis among them was 24 months. [3] Other studies reported that TB is associated with longer duration of dialysis. [10]

In this study, only 16% of TB HD patients have a history of TB. Several studies found that the rate of the previous history of TB among TB diagnosed HD patients is relatively low. In a study conducted in India among TB diagnosed HD patients, a history of TB was only 8%. [11] The same observation was noticed in another study conducted in Greece which found the percentage was only 2%. [12]

Fifty-eight percent of patient presented with extrapulmonary TB. TB lymphadenitis was the most common presentation of extrapulmonary TB in our HD patients. Several studies reported that extrapulmonary TB is the most common presentation among ESRF patients. [13],[14],[15],[16],[17],[18],[19] Other studies reported that TB lympha-denitis was the most common extrapulmonary TB among HD patients. [14],[20]

Fifty percent of patients with pulmonary TB have been diagnosed by finding AAFB in the sputum. Some studies pointed out the difficulty of diagnosing pulmonary TB among ESRF because the AAFB is difficult to be seen in the sputum of ESRF patients. [21] However, other studies found that 30% of ESRF patient diagnosed as TB by finding AAFB in the sputum. [6] In our study, 50% of AAFB smear negative pulmonary TB patients were diagnosed based on positive PCR. Several studies reported the increased rate of detection of TB by PCR, especially in smear-negative TB. [22],[23],[24] Other studies reported an increased rate of detection of TB among smear negative in immunocompromised patients. [25],[26]

In the cases of abdominal and spinal TB, the diagnosis was made by imaging. Patients with abdominal TB usually present with peritonitis and mesenteric lymphadenitis. [27],[28] The combination of clinical evidence of TB with characteristics findings in computed tomography of the abdomen can strengthen the diagnosis of abdominal TB. [29],[30] For spinal TB, the diagnosis was made by magnetic resonant image (MRI). MRI is highly sensitive in detecting spinal TB. [31] Cases of pleural TB and TB lymphadenitis were diagnosed base on histology.

There were some limitations in our study. We believe that a number of TB patients among HD patients in Khartoum are underestimated because patients need to be screened properly for TB in HD setting, and one needs a high index of clinical suspicion because of the difficulty in making the diagnosis. A full investigation to detect TB in HD patients sometimes is difficult due to financial constraints.

 Conclusion



Patients on maintenance HD are at an increased risk of TB, and further epidemiological studies are needed to evaluate this further. Diagnosis of TB among HD patients needs a high index of suspicion. There is increased need for establishing a screening scheme for TB among HD patients.

Conflict of Interest

The authors declare that the article is original, does not infringe upon any copyright, is not under consideration by another journal, and has not been published previously. All data collected during the study is presented in this manuscript. Each author believes that the manuscript represents honest work. Also, there is no conflict of interest.

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