Letter to the Editor
“Latent tuberculosis vs active tuberculosis in dialysis patients: lessons from an epidemiological study in orense”
“Tuberculosis latente vs tuberculosis activa en pacientes en diálisis: enseñanzas de un estudio epidemiológico en orense”
Maria Hernansanz Perez
, Maria Jesús Camba Caride, Cristina Pérez Melón, Beatriz Millán Diaz
Corresponding author
Servicio de Nefrología, Complejo Hospitalario Universitario de Ourense, Ourense, Spain
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array:1 [ 0 => array:2 [ "paginaInicial" => "308" "paginaFinal" => "310" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Un fracaso renal relacionado con el mundo felino" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 639 "Ancho" => 2533 "Tamanyo" => 346424 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Haematoxylin-eosin and Periodic Acid-Schiff (PAS) positive sample from a renal cast seen under an optical microscope. In the image on the left, two renal glomeruli can be seen, showing a large extracellular growth containing numerous nuclei (cellular crescent) (red arrows), reducing the renal tuft (green arrow). The central image shows a glomerulus with a cellular crescent. The image on the left shows positive IgM immunofluorescence.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Adriana M. Cavada-Bustamante, Clara Sanz García, Natalia Menéndez García, María Gago Fraile, Blanca Vivanco Allende, Joaquín Bande Fernández" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Adriana M." 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If the TT or IGRA were positive, patients were evaluated by the tuberculosis unit (TBU) which, after ruling out active TB, with the tests that they considered appropriait was de decided whether or not to start chemoprophylaxis.</p><p id="par0020" class="elsevierStylePara elsevierViewall">We evaluated 209 patients, seven of which were excluded due to having previously suffered from active TB. Of the remaining 202, 70.29% were on HD.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In patients on PD, 18.3% had TT<span class="elsevierStyleSup">+</span> compared to 12.7% on HD.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Patients who were TT<span class="elsevierStyleSup">−</span> were given an IGRA test, which was positive in 18.8% of patients on HD and 11.8% in patients on PD.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Patients with LTI were classified into two groups: those TT<span class="elsevierStyleSup">+</span>; and those TT<span class="elsevierStyleSup">−</span> and IGRA<span class="elsevierStyleSup">+</span>. The second group were older patients, with a longer time on dialysis and with a higher Charlson index (CI).</p><p id="par0040" class="elsevierStylePara elsevierViewall">A total of 53 patients had LTI. Eleven cases (20.75%) did not receive treatment, either due to excessive associated comorbidity or patient refusal. Thirty-seven cases (69.81%) completed the prophylaxis treatment according to the TBU protocol, without notable side effects, and at the end, treatment had to be abandoned in five cases (9.43%) because of side effects.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The demographic characteristics and results are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">During follow-up, three patients developed TB, all extrapulmonary; six months after completing prophylaxis, one of these patients on the PD programme developed peritonitis with a negative culture and was diagnosed with miliary TB. Another patient on HD who was TT<span class="elsevierStyleSup">−</span> and IGRA<span class="elsevierStyleSup">+</span>, interpreted as LTI, developed a pericardial effusion with haemodynamic compromise a few weeks after starting prophylaxis. Although there was no microbiological diagnosis, after antituberculosis treatment, which he completed successfully, produced a significant clinical and radiographic improvement.</p><p id="par0055" class="elsevierStylePara elsevierViewall">A patient on HD who stopped chemoprophylaxis after developing a severe rash had to be admitted to hospital with pericardial effusion and constitutional syndrome. The clinical, laboratory and radiological data were consistent with TB, although it could not be confirmed histologically. In accordance with the TBU, he was started on antituberculosis treatment, with clear clinical improvement.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In patients on RRT, the combination of TT and IGRA is required to diagnose LTI, particularly in older adult patients who have been on dialysis for longer and have greater comorbidity, because in this group TT performs poorly.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–6</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Prior to starting prophylaxis, active disease must be ruled out, particularly in patients on the kidney transplant waiting list.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> It is important to remember that in patients on dialysis, TB is generally extrapulmonary,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> therefore a simple chest X-ray or sputum cultures may not be sufficient to make the diagnosis. A high degree of clinical suspicion is essential to come up with a diagnosticsince histological diagnosis is not always possible, as was the case in our patients. The post-treatment clinical and radiological improvement they experienced supported the diagnosis of active TB.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Ruling out LTI in patients on the kidney transplant waiting list is necessary. Patients IGRA<span class="elsevierStyleSup">−</span> pre-transplant have a very low risk of subsequently developing active TB.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> If necessary, this screening and treatment should preferably be performed in the advanced chronic kidney disease (ACKD) clinic.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Chemoprophylaxis in patients on RRT or being followed in the ACKD clinic who are not going to be included in the kidney transplant waiting list should be considered on an individual basis, assessing risk-benefit based on the associated comorbidity in each case.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0115" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">IGRA: Interferon Gamma Release Assay tuberculosis test; LTI: latent tuberculosis infection; TT: tuberculin test.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Charlson index: relates long-term mortality to patient comorbidity. 0–1 point: absence of comorbidity; 2 points: low comorbidity; >3 points: high comorbidity.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Ulibarri index: assessment of the patient's degree of malnutrition. 0–1: no malnutrition; 2−4: mild malnutrition; 5−8: moderate malnutrition; >8: severe malnutrition.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total patients (N<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>202) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">TT<span class="elsevierStyleSup">+</span> patients (N<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>24) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">TT<span class="elsevierStyleSup">−</span>/IGRA<span class="elsevierStyleSup">+</span> patients (N<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>29) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p-value \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">65.9 (14.20) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">64.8 (11.04) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">73.2 (9.90) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean time on dialysis (months) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45.0 (44) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27.7 (28.82) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">46.8 (53.13) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.098 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Charlson index \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.7 (3.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.9 (2.93) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.1 (3.51) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.021 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ulibarri index \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.8 (2.26) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.7 (1.95) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.1 (0.51) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.078 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3704412.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Demographic characteristics and study results.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epidemiology of tuberculosis in Galicia, Spain, 16 years after the launch of the Galician tuberculosis programme" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "E. 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