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Table of Content - Volume 10 Issue 2 - May 2018
Incidence of pulmonary tuberculosis in chronic renal failure patients on dialysis vs non dialysis in rural population
Chaudhari Abdul Hameed Abdul Shikur1, Munot Pritesh Naresh2*
1Associate Professor, 2Resident, Department of Medicine MIMSR Medical College, Latur, Maharashtra, INDIA. Email: laturcritical@gmail.com
Abstract Background: The incidence of CKD is rising in rural populations in our country which is proving a heavy burden on healthcare and economy. Due to reduced awareness about the disease process, the complications are more particularly in this group of patients. Tuberculosis is one of the most common infections worldwide which affects almost one third of the world population. The risk of active tuberculosis is more in patients with reduced immunity like HIV, organ transplant etc. End stage renal disease particularly uremia is a immunosuppressive condition. It affects both innate immunity and adaptive immunity by affecting the motility of T cells and their ability to kill ingested intracellular pathogen. Aim: The aim of the study was to identify the risk of TB in CKD patients and the impact of hemodialysis on the affection of tuberculosis. Methodology: The study was done in a tertiary care hospital in a rural setup over a period of 1 year from August 2015 to July 2016. The study included 78 patients and were divided into 3 groups. Consent was taken. 1st group had 25 patients of ESRD who were not undergoing dialysis. 2nd group had 23 patients undergoing dialysis since less than 1 year. 3rd group had 40 patients with regular dialysis less than thrice per week since more than 1 year. All patients were subjected to the following: 1Complete history, physical examinations, 2Routine blood investigations CBC, LFT KFT, 3CXR-PA view 4Sputum examination in relevant patients with CXR showing suspicion of pulmonary tuberculosis 5Pleural fluid examination in relevant cases with routine cytological, ADA examinations, 6 BAL and gene Xpert in 4 patients with Xray suggestive of tuberculosis but Zn staining negative. 7Tuberculin testing was done in all subjects, 8USG Abdo to rule out abdominal tuberculosis, All the information was subjected to statistical analysis, Conclusion: We found that there was an increased risk of Tb in CKD patients. Though hemodialysis reduces uremia, it does not seem to reduce the risk of tuberculosis in CKD patients. The patients with CKD and tuberculosis had statistically significant levels of S.creat and Blood urea nitrogen as compared to non TB patients with CKD . Key Word: pulmonary tuberculosis, chronic renal failure.
INTRODUCTION A Tuberculosis is major health problem globally as well as in our country. According to CDC report 2015, 9.6 million people were infected with tuberculosis globally and one fifth of the total around 2.2 million occur in India1. Almost one third of the world is infected with mycobacterium tuberculosis (MTB)2. India has the largest burden of tuberculosis patients mostly because of population size, overcrowding, poverty, slums, malnutrion, poor health care setup and reach3. There is increased risk of tuberculosis in immunocompromised patients along with an increased mortality rates to upto around 75%(4). Patients with HIV, organ transplantation, prolonged treatment with steroids, chemotherapy patients, immunodeficiency states have a higher risk of infection along with increased mortality. This emphasizes the importance of the cellular immunity for efficient control of Mycobacterium tuberculosis. Moreover, the presence of M. tuberculosis-specific CD4+ T-cell immunity is used as a surrogate marker for a previous contact5. It is likely that CKD patients have a increased incidence of tuberculosis in those parts of the world with a higher rate of incidence and prevalence of tuberculosis. Active TB in immunocompromised patients can pose with a number of diagnostic challenges Due to the impaired immune response, patients maybe clinically oligosymptomatic in the beginning of active disease, and its diagnosis is often delayed due to atypical presentations and more frequent extrapulmonary dissemination6. Along with increased rates, the course of TB can be aggravated due to weakened immune system. CKD patients mostly end stage renal disease patients have a higher degree of risk of tuberculosis mostly because of uremia which causes decreased immunity along with reduced killing capacity of macrophages of the Mycobacterium bacilli7.
AIM The aim of the study was to evaluate the incidence of pulmonary tuberculosis in CKD patients along with the presentation and impact of hemodialysis.
METHODOLOGY The study was conducted in a tertiary care centre in a rural setup in a period of 1year starting from August 2015 to July 2016.Clearance from ethical committee was appropriately taken. 78 patients were selected for the study after obtaining consent. Patients with previous history of tuberculosis and those with history of known close contacts with tuberculosis were excluded from the study. The patients were divided into 3 groups according to the stages and the need of dialysis: Group1 had 25 patients with CKD and not on dialysis (stage 1-3 of CKD). Group 2 had 23patients of CKD on hemodialysis since less than an year. Group 3 had 40 patients of CKD on hemodialysis since more than an year with weekly twice or thrice cycles. All patients were subjected to
RESULTS Table 1 shows that 18 patients out of 78 were found to have tuberculosis which amounts to about 23.07% patients. 60 patients were free from any form of pulmonary tuberculosis. This tuberculosis included both those with pulmonary tuberculosis diagnosed by ZN staining and those with pleural effusion diagnosed by biochemical methods. Figure 1 Figure 2 Figure 3 Table 2 divides the tuberculous patients into their respective groups. 4(16%) of group 1, 7 (30.4%) of group 2 and 7 (17.5%) were diagnosed with tuberculosis. There were no differences statistically in the three groups of patients which means that there was no statistical evidence of incidence of tuberculosis to be more predominant in any group of CKD patients. Table 1:
Table 3 shows the ZN positivity in each groups. Out of 11 patients with from group 1 whose sputum was sent was ZN staining, 3 came out to be positive, similarly 6 of 16 and 6 of 22 from group 2 and group 3 came ZN positive respectively Table 4 shows that 11 out of 78 patients were diagnosed to have pleural effusion out of which 4 (36.3%) patients had tuberculous pleural effusion and 7 were non tuberculous. Table 5 shows sex wise distribution of patients in each group with tuberculosis. In group 1 of the 4 patients, 2 were males and 2 were females, of the group 2patients 4 were males and 3 were females. Group 3 had 4 males and 3 females with tuberculosis.
Table 2
Table 6 shows symptom wise distribution of patients with tuberculosis. The predominant symptoms of group 1 were cough and fever while those of group 2 were loss of weight and reduced appetite and that of group 3 were cough and reduced appetite. Table 3:
Table 7 shows group wise distribution of S.creat and blood urea nitrogen. There were no statistical differences with respect to S.creat and BUN and tuberculosis in respective groups.
Table 4:
Table 8 shows S. creat and blood urea nitrogen changes in tuberculous as well as non tuberculous patients. There were statistically significant differences in the levels of S.creat and BUN which implies that those with tuberculosis have significant values of S. creat as well as BUN as compared to non TB patients.
Table 5:
DISCUSSION Tuberculosis is major health problem globally as well as in our country. According to CDC report 2015, 9.6 million people were infected with tuberculosis globally and one fifth of the total around 2.2 million occur in India1. Almost one third of the world is infected with mycobacterium tuberculosis (MTB)2. India has the largest burden of tuberculosis patients mostly because of population size, overcrowding, poverty, slums, malnutrion, poor health care setup and reach3. There is a increased risk of tuberculosis in immunocompromised patients along with an increased mortality rates to upto around 75%4. Patients with HIV, organ transplantation, prolonged treatment with steroids, chemotherapy patients, immunodeficiency states have a higher risk of infection along with increased mortality. Patients with chronic renal failure have uremia which leads to immunosuppression with reduced action of T cells and affection of the cell mediated immunity. T cells are mainly responsible for cell mediated immunity and they identify and kill the intracellular pathogen7.The response of T cells to organisms, the delayed hypersensitivity as well as the phagocytic activity of the macrophages is depressed in the presence of uremia. And hence the chances of patients acquiring TB is more in the presence of uremia9. Persons undergoing HD are at a further 10% risk of contracting tuberculosis10 Nosocomial Tb, the close contacts of patients during HD, the contact of CKD patients with TB bacilli from patients with TB in hospitals, frequent admissions all are responsible for tuberculosis in these patients10. Also patients with CKD have a reduced body mass index, reduced weight, reduced appetite, anemia, low Vitamin D levels, all of which increase further the risk of getting infected with tuberculosis11. The presentation of TB in CKD patients can be quite deceptive with low grade fever, reduced appetite, weight loss, cough, breathless also being common symptoms of CKD patients. Hence a higher degree of suspicion is required to diagnose patients with tuberculosis as the presentation can be oligosymptomatic to atypical more frequently. In our study, 18 of 78 patients of CKD had tuberculosis with 15 patients being ZN positive tuberculosis and 4 being positive with pleural effusion study. 1 had both pleural fluid positivity along with ZN positivity. There were no significant differences in the three groups with regards to tuberculosis but there was increased number of susceptible individuals in group 3 with HD from more than an year mostly because of increased hospital visits. 11 patients had pleural tapping performed on them with positive results in 4 patients. The extra pulmonary sites that can be affected in tuberculosis include lymph nodes, bone, Gastrointestinal tract, genitourinary tract, peritonitis, military tuberculosis, and pyrexia of unknown origin12. Dissemination is more common in immunocompromised patients and it is important for one to know about the localisation of various sites of tuberculosis along with a higher degree of suspicion. Atypical manifestations are seen in 20-22% of patients13.TB is generally diagnosed in patients within 1st year of starting of HD because of the seriously impaired immunity in the 1st year of starting of HD14. Also because of the increased medical contact, the probability of getting diagnosed with tuberculosis increases in end stage renal disease patients with dialysis which helps in timely starting of anti-tuberculous medications and reducing mortality and infectiousness. In our study there were significant changes among the presentation of patients in each groups . The predominant symptoms of group 1 were cough and fever while those of group 2 were loss of weight and reduced appetite and that of group 3 were cough and reduced appetite. The tuberculous patients also showed significant differences as compared with non tuberculous patients in terms of S.creatinine and uremia which proves indirectly that increased levels of these two increases the risk of affection with tuberculosis. Due to dialysis and economic burden of treatment on patients with CKD, patients’ willingness for investigations decreases which in turn leads to reduced diagnosis of tuberculosis. Schemes like RGJAY and other insurance schemes reduce this economic burden on patients and hence the probability of diagnosis of tuberculosis also increases. So increasing such schemes and their coverage to include the rural population with CKD will benefit these patients. India being the hotbed for tuberculosis and the ever increasing number of tuberculosis patients with MDR and XDR TB, the need for urgent diagnosis and treatment of tuberculosis becomes the key of reducing the burden of TB. CKD patients, being immunosuppressed are not only at risk of infection with resistant organism but also being one of the sources of spread of infection to the society. Focusing more on these patients will infact reduce government load on TB identification and management. The probability of tuberculosis should always be considered in CKD patients with complains of weight loss, cough, fever and they should be actively managed and investigated. Every possible effort should be made to help diagnose the patients. Symptoms of uremia like fatigue, weight loss, reduced appetite may concele the effects of tuberculosis and this might lead to delay in diagnosis along with Improper diagnosis and death of the patient. So, a possibility of tuberculosis should always be entertained in a CKD patient with generalised complaints. This higher vigilance amongst medical practioners can not only help in increasing the livelihood of patients with end stage renal disease but also help in reducing the burden of tuberculosis in our country along with the world.
CONCLUSION Patients with Chronic renal failure are at a higher risk of getting affected with tuberculosis and should be properly and thoroughly screened.
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