| Tuberculosis(TB)is a global public health problem that seriously endangers public health,with high morbidity and mortality.China is the world’s second-rank country with a high burden of tuberculosis.In patients with end stage renal disease(ESRD)on long-term maintenance hemodialysis(MHD),due to low immune function and frequent hospital contact history,etc.,the incidence of tuberculosis is much higher than that in the general population.Furthermore,the clinical manifestations,diagnosis and treatment in it may also have certain particularities.This study aims to explore the clinical characteristics of tuberculosis,pulmonary tuberculosis(PTB)and extrapulmonary tuberculosis(EPTB),sputum-positive pulmonary tuberculosis and sputum-negative pulmonary tuberculosis in patients with ESRD on MHD,and provide a basis for clinical diagnosis and treatment.This study retrospectively analyzed a total of 133 patients with ESRD complicated by tuberculosis who were treated at the Tuberculosis Department of the Eighth Medical Center of PLA General Hospital from July 2012 to February 2021 and underwent MHD treatment in the blood purification center.The comparative analysis was done in three aspects,that is,TB,PTB and EPTB,sputum-positive pulmonary tuberculosis and sputum-negative pulmonary tuberculosis,to probe the patterns in clinical characteristics and treatment prognosis.In ESRD patients receiving MHD treatment in our hospital,the proportion of those complicated with tuberculosis was 3.3%.Among those133 cases of tuberculosis and ESRD patients,the average age was53.83±15.19 years,and the proportion of male was relatively high(72.9%).Their underlying renal disease was mainly primary glomerulonephritis(74.3%),and the complications in them mainly included hypertension(73.7%)and diabetes(40.2%).The rate of tuberculosis occurred more than1 year after dialysis was relatively high(60.2%).Lung was the main lesion location(83.5%),and in most cases,both left and right lungs were affected in CT reading(61.7%).Fever(47.4%),cough and expectoration(48.1%)were the main symptoms firstly observed.The positive rate of Sputum Mycobacterium tuberculosis culture was 23.4%,of purified protein derivative(PPD)test was 51.9%,and of interferon gamma release assay(IGRA)was 55.7%.The proportion of Lymphocytes(50.4%),hemoglobin(81.2%),and albumin(68.4%)decreased,and the proportion of erythrocyte sedimentation rate(ESR)(85.7%),C-reactive protein(CRP)(87.2%),adenylate deaminase(21.8%)and phosphorus(31.6%)increased were relatively high.The anti-tuberculosis treatment protocol was mainly the isoniazid or pasoniazid + rifampicin or rifapentin,individualized combination of ethambutol and(or)pyrazinamide and levofloxacin and other anti-infective treatments.Twenty-two patients(16.5%)had adverse drug reactions occurred during treatment,including numbness of the lower limbs and blurred vision,etc.The improvement rate on treatment was93.2%.In the comparison of PTB group and EPTB group,male was the dominant gender in both groups(80.5% vs.58.7%),but the proportion of female in the EPTB group(41.3%)was higher than in the PTB group(19.5%)(P<0.05).There were no significant differences between the two groups in age,underlying kidney disease,comorbidities,dialysis duration,and tuberculosis detection time-point after dialysis.Among the first observed symptoms,the proportion of cough and expectoration(59.8%)and fever(60.9%)in the PTB group was significantly higher than in the EPTB group(23.9% and 28.3% respectively,P<0.05),and the proportion of pain at lesion location(8.0%)was significantly lower than the EPTB group(41.3%,P<0.05).CT or MRI imaging examination was the dominated method in both PTB group and EPTB group(67.8% vs.76.1%),the second common diagnosis method was Sputum smear to find acid-fast bacilli or sputum Mycobacterium tuberculosis culture(26.4% vs.6.5%)and needle biopsy(5.7% vs.17.4%)respectively.There was a significant difference between the two groups(P<0.05).There was no significant difference in the positive rate of IGRA between the two groups.In the PTB group and EPTB group,the proportion of lymphocytes,hemoglobin,and albumin decreased(54.0% vs.45.7%,81.6% vs.80.3%,67.8% vs.69.6%),and the proportion of ESR and CRP increased(86.0% vs.88.9%,92.9% vs.84.4%)were relatively high,but there was no statistical difference between groups.Both groups were treated with anti-tuberculosis drugs,and 1 case in EPTB group with anti-tuberculosis drugs plus surgery of tuberculosis focus clearance.There was no significant difference in the incidence of adverse reactions between the two groups(14.9% vs.19.6%),and the improvement rate after treatment(93.1% vs.93.5%)was similar.In the comparison of sputum-positive pulmonary tuberculosis group and sputum-negative pulmonary tuberculosis group,the patients were predominantly male(84.6% vs.76.1%),middle-aged or elderly(58.85±14.96 vs.53.30±16.31 years old)in both groups.The proportion of patients with primary glomerulonephritis as the main underlying kidney disease was higher in sputum-negative pulmonary tuberculosis group(57.7% vs.83.1%,P<0.05).In terms of the first observed symptoms,cough and expectoration were more frequent seen in sputum-positive pulmonary tuberculosis patients(84.6% vs.52.1%,P<0.05).The results of serological examination showed that the white blood cells,neutrophils,monocytes and albumin of the two groups were significantly different(P<0.05).And the neutrophil to lymphocyte ratio(NLR),monocyte to lymphocyte ratio(MLR)differences were also significant(P<0.05).The chest CT findings of sputum-positive pulmonary tuberculosis showed a high proportion of pleural effusion(73.1% vs.39.4%,P<0.05)and cavity formation(38.5% vs.16.9%,P<0.05),sputum-negative pulmonary tuberculosis had a higher proportion of strip shadows(11.5% vs.35.2%,P<0.05).The efficacy of anti-tuberculosis treatment in both groups were better(88.5% vs.94.4%).Multivariate logistic regression analysis found that Secondary glomerulonephritis(OR: 5.723,95%CI: 1.521～21.535),cough and sputum(OR: 5.094,95%CI: 1.199～21.640),pleural effusion(OR:6.259,95%CI: 1.585～24.716),HIGH MLR(OR: 3.952,95%CI:1.133～13.790)are risk factors for sputum-positive pulmonary tuberculosis in patients with MHD ESRD.In summary,the majority of ESRD patients with tuberculosis who have undergone MHD treatment are middle-aged and elderly men.Tuberculosis occurs mostly more than one year after dialysis.In addition,there are significant differences in the sex ratio,first symptom and diagnosis method between PTB and EPTB,sputum-positive pulmonary tuberculosis and sputum-negative pulmonary tuberculosis.In sputum-positive pulmonary tuberculosis,the content of MTB in lesions,the extent of the immune response,and the infectivity were high,thus we should be alert to such risk factors as secondary glomerulonephritis,cough and expectoration,pleural effusion,HIGH MLR.Therefore,periodic screening,identification and discrimination of tuberculosis should be carried out in dialysis patients,to facilitate early diagnosis and individualized treatment,reduce the possibility of tuberculosis spreading through air in hospitals,improve prognosis,and reduce the morbidity and mortality of patients. |
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