Incidence of tuberculosis is high in chronic kidney disease patients in South East England and drug resistance common

Abstract

The risk of tuberculosis (TB) is significantly increased in chronic kidney disease (CKD). Data on TB in CKD in the UK are sparse; most information stems from countries with high background prevalence. The aim of this study was to estimate the incidence of TB in CKD patients in South East London and to describe the epidemiology, treatment, and outcome. CKD patients with TB between 1994 and 2010 were identified retrospectively. Data were collected on type of renal replacement therapy, the method of TB diagnosis, disease site, treatment regimens, and risk factors. Forty patients were identified of whom 67.5% had CKD stages IV-V. Sixty-five percent were from non-UK born ethnic minorities. Median time from diagnosis of CKD to TB development was 12 months (range 0-192 months). Cumulative incidence of TB was 1267/100,000 [95% confidence interval (CI): 630-1904; 85 Â background UK rate] in hemodialysis patients; 398/100,000 (95% CI: 80-1160; 26 Â background UK rate) in peritoneal dialysis; and 522/100,000 (CI: 137-909; 35 Â background UK rate) in transplant recipients. Sixty-three percent of patients had pulmonary TB and 25% of patients with culture-positive TB had resistant isolates. Fifty percent of patients were immunosuppressed due to drugs, diabetes, and/or retroviral disease. Treatment regimens were according to recent national guidance in 73% of cases. Seventy-six percent of patients experienced side effects. Greater awareness of risk factors, drug resistance, treatment regimens, and potential side effects is needed. ARTICLE HISTORY

An update of management of latent tuberculosis infection and active disease in patients with chronic kidney disease

“…However, the figures from a large UK renal unit suggest that hemodialyzed patients at risk could well benefit from screening, whether or not they proceed to transplant surgery. 9 In a recent study from Turkey, Sehan et al 20 demonstrated that 6.2% of patients on hemodialysis with a positive QFT result progressed to active disease over a 5 -year follow -up compared with 1.1% of healthy controls.…”

“…In addition to this, patients on peritoneal dialysis who are at risk of intra -abdominal infection also require special consideration. 9,21 A chest radiograph should be performed as part of the workup of all renal patients to show any evidence of previous TB disease, but also so that future radiographs can be compared with previous studies, and any new infiltrates warrant further investigation. Further site -specific investigations such as abdominal ultrasound, computed tomography, or spinal magnetic resonance imaging should be considered based on symptoms.…”

“…The sometimes indiscriminate use of chemoprophylaxis in all transplant recipients may account for the reduced incidence of active disease found in these patients compared with those on dialysis. 6,8,9 A recent study from Saudi Arabia indeed demonstrated that expanded isoniazid chemoprophylaxis for deceased -donor kidney recipients was responsible for a significant reduction in post -transplant TB in a moderate -incidence country.…”

“…The TBNET study revealed that the between -test agreement was higher between IGRAs, which also generally had a higher rate of and 25% of patients with positive culture results had organisms resistant to at least one of the first--line drugs. 9 This means that the diagnosis of both active disease and LTBI is crucial in patients with CKD. For example, in our unit alone in the years 2015 and 2016, we reported 2 cases of active TB (presumed reactivation from undiagnosed LTBI) in transplant recipients born in Africa and Asia, and 1 case in an indigenous patient with no history of prior exposure.…”

“…Patients with renal disease are at an increased risk of side effects, compared with those with normal renal function. 9 Given the high incidence of active TB in patients with CKD, particularly those due to undergo transplantation, and the earlier paucity of evidence on the use of IGRA testing in these patients, one approach has been to treat all transplant recipients with chemoprophylaxis. This presents 2 difficulties: one is that this fails to identify patients with active disease and the second is that chemoprophylaxis is not without risk.…”