El Bardai Ghita, Kabbali Nadia, Baba Hanae, Chouhani Basmat Amal, Sqalli Houssaini Tarik
Nephrology, Dialysis, and Transplantation Department, Hassan II University Hospital, Fez, MAR.
Laboratory of Epidemiology and Health Science Research (ERESS), Faculty of Medicine-Fez, Sidi Mohammed Ben Abdelalh University, Fez, MAR.
Cureus. 2022 Oct 16;14(10):e30369. doi: 10.7759/cureus.30369. eCollection 2022 Oct.
Due to the predominantly cellular immunosuppression, infections are frequent in chronic dialysis patients, in particular tuberculosis (TB). The main objective of our study is to evaluate tuberculosis healthcare delay in dialysis patients and to raise the diagnostic challenge in these patients.
The study is retrospective and multicenter including tuberculosis cases of chronic dialysis patients either in hemodialysis (HD) or peritoneal dialysis (PD) in the central region of Morocco during a 10-year period between 2012 and 2021.
We included 94 patients, five of whom were in PD, with a mean age of 50.79 ± 16.72 years, and a sex ratio of 0.67. The time between the initiation of dialysis and the onset of the clinical and biological presentation was 50.3 ± 67.12 months. The most frequent initial manifestations were an alteration of the general state (85.1%), a biological inflammatory syndrome (83%) or a prolonged fever (70.1%). Among our 94 patients, the diagnosis was confirmed with bacteriological evidence only in 18 cases (19.1%), by identification of Koch's Bacillus (BK) in 13 cases, by molecular biology test (GeneXpert; Cepheid, Inc., Sunnyvale, CA, USA) in five cases. The diagnosis of tuberculosis was presumptive in most cases (79 cases), i.e. 80.9%. Twenty-one patients underwent the interferon gamma release essay test (QuantiFERON; Qiagen, Hilden, Germany) which was positive in 14 patients. Thirty-four (36.1%) cases had a histological diagnosis. The remaining patients were offered a trial treatment. Tuberculosis localization was mostly extra-pulmonary (75.5%): lymph node (23.4%), pleural (13.8%), peritoneal (13.8%), whereas it was pulmonary in 23 cases (24.5%). Most of our patients had a clear delay in management from symptom onset to initiation of anti-TB treatment 78.9% (time >21days) vs 21.1% (time ≤21days). The median time to management delay was 46.5 interquartile range (IQR) (28.5-90), the mean delay was 78.4 ± 87.9 (6-360). All patients were treated according to the RHZE/RH protocol (R: rifampicin, H: isoniazid Z: pyrazinamide and E: ethambutol), with a duration between six and 18 months. Side effects associated with anti-tuberculosis treatment were observed in half of the patients (51.1%). The evolution was favorable with remission and improvement of the general condition in 90% of cases. Two cases of resistance were noted in our series. The overall mortality was 7.7%.
We have confirmed a delay in the diagnosis and treatment of tuberculosis in chronic dialysis patients. This can be explained by the often atypical or incomplete clinical and paraclinical presentation and the extra-pulmonary localizations, making diagnosis difficult in this population whose prognosis remains poor. It is therefore necessary to establish a diagnostic approach that is adapted to the specificities of these high-risk patients within the framework of a national tuberculosis control program.
由于慢性透析患者主要存在细胞免疫抑制，感染很常见，尤其是结核病（TB）。我们研究的主要目的是评估透析患者结核病的医疗延误情况，并提出这些患者的诊断挑战。
本研究为回顾性多中心研究，纳入了2012年至2021年期间摩洛哥中部地区接受血液透析（HD）或腹膜透析（PD）的慢性透析患者的结核病病例。
我们纳入了94例患者，其中5例接受腹膜透析，平均年龄为50.79±16.72岁，性别比为0.67。透析开始至临床和生物学表现出现的时间为50.3±67.12个月。最常见的初始表现为一般状况改变（85.1%）、生物学炎症综合征（83%）或长期发热（70.1%）。在我们的94例患者中，仅18例（19.1%）通过细菌学证据确诊，13例通过鉴定结核杆菌（BK）确诊，5例通过分子生物学检测（GeneXpert；美国赛沛公司，加利福尼亚州桑尼维尔）确诊。大多数病例（79例，即80.9%）结核病诊断为推定诊断。21例患者接受了干扰素γ释放试验（QuantiFERON；德国希尔德凯杰公司），其中14例呈阳性。34例（36.1%）病例有组织学诊断。其余患者接受了试验性治疗。结核病定位大多为肺外（75.5%）：淋巴结（23.4%）、胸膜（13.8%）、腹膜（13.8%），而23例（24.5%）为肺部。我们的大多数患者从症状出现到开始抗结核治疗的管理存在明显延误，78.9%（时间>21天）对21.1%（时间≤21天）。管理延误的中位时间为46.5四分位间距（IQR）（28.5 - 90），平均延误为78.4±87.9（6 - 360）。所有患者均按照RHZE/RH方案（R：利福平，H：异烟肼，Z：吡嗪酰胺，E：乙胺丁醇）进行治疗，疗程为6至18个月。一半患者（51.1%）观察到与抗结核治疗相关的副作用。90%的病例病情好转，全身状况缓解并改善。我们的系列研究中发现2例耐药病例。总死亡率为7.7%。
我们证实了慢性透析患者结核病诊断和治疗存在延误。这可以通过临床和辅助检查表现通常不典型或不完整以及肺外定位来解释，这使得该人群的诊断困难，其预后仍然很差。因此，有必要在国家结核病控制项目框架内建立一种适应这些高危患者特殊性的诊断方法。
