الفهرس 
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Abstract
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The incidence of active TB and attendant mortality is increased in
patients with impaired cellular immunity, such as HIV infected patients,
solid organ and stem cell transplant recipients, and patients with end
stage renal failure. The relative risk for TB varies with the type of
immunodeficiency and mortality rates may be as high as 75%. This
emphasizes the particular importance of the cellular arm of the adaptive
immune response 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 contact . Despite
the availability of highly efficacious treatment for TB, it remains a major
global health problem. In 1993, the World Health Organization (WHO)
declared TB a global public health emergency, at a time when an
estimated 7–8 million cases and 1.3–1.6 million deaths occurred each
year. In 2010, there were an estimated 8.5–9.2 million cases and 1.2–1.5
million deaths (including deaths from TB among HIV-positive people).
TB is the second leading cause of death from an infectious disease
worldwide (after HIV, which caused an estimated 1.8 million deaths in
2008 .
It is likely that TB will be seen more frequently in patients with
chronic kidney disease (CKD) as people from the areas of the world with
high background levels of TB are also at increased risk of CKD. Active
TB in immuno-compromised patients can pose a number of challenges.
Due to the impaired immune response, patients may be clinically
asymptomatic in the beginning of active disease, and its diagnosis is often
delayed due to atypical presentations and more frequent extra-pulmonary
dissemination. Active TB is further aggravated by a significantly higher morbidity due to a more fatal course in the face of a weakened immune
system. In addition, treatment is frequently complicated due to complex
drug interactions and altered pharmaco-kinetics. End-stage renal disease
(ESRD) and particularly uraemia is a known contributor to immunosuppression. The causative factors of the immunosuppression are
complex and disrupt the cell-mediated immune functions which include
identification and killing of intracellular pathogens such as M.
tuberculosis.
The aim of this work was to evaluate the increasing risk of
pulmonary tuberculosis among patients with chronic renal failure and the
impact ofhemodialysis.
Patients and Methods:
This study was carried out at Nephrology Unit and Chest
Department, Zagazig University Hospitals during the period from April
2012 to Jan 2013. The study included a total number of 140 patients with
chronic renal failure (92 males and 48 females), with mean a age of (49 ±
6.4 years). Patients were classifiedto three groups:
- group Ι: Included 40 Patients(24 male and 16 female with mean
age 48.3±10.4) with chronic renal failure and not on dialysis.
- group ΙΙ: Included 50 (34 male and 16 female with mean age
49.8±9) Patients with chronic renal failure and on regular hemodialysis
three settings per week for less than one year.
- group ΙΙΙ: Included 50(34 male and 16 female with mean age
48.5±9.3) Patients with chronic renal failure and on regular hemodialysis
three settings per week for more than 1 year.
Summary and conclusions
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All patients were subjected to the following:
1) History taking and medical evaluation including general and
local examinations.
2) Laboratory investigations:
§ Serum creatinine & blood urea.
§ ALT & AST& serum bilirubin & serum albumin.
§ Complete Blood Count (CBC).
§ Erythrocyte Sedimentation Rate (ESR).
§ Fasting & post-prandial blood glucose level.
3) Plain chest X-ray:Postero-anterior and lateral views for all
patients.
4) Sputum Ziehl–Neelsen staining for acid fast bacilli in patients
complainning from expectoration.
5) Sputum induction (for Ziehl–Neelsen staining) in patients who
had chest X-ray suspecting pulmonary TB without expectoration. The
patient was considered suspect for pulmonary tuberculosis if there were
signs or symptoms consistent with pulmonary tuberculosis and had
radiological picture of the chest consistent with pulmonary tuberculosis
(apical infiltrations, cavitations, calcifications or hilar lymphadenopathy)
with –ve sputum ZN for acid fast bacilli.
6) Tuberculin Skin Testing (TST).
7) Bronchoscopy to obtain BAL for bacteriological examination
for acid fast bacilli in 10 cases in whom Plain chest X-ray was suspect of
Summary and conclusions
76
pulmonary TB while there was no sputum production and induction of
sputum failed to produce proper sample.
8) Pleural fluid aspiration and full chemical, bacteriological and
cytological examination in patients presented by pleural effusion ( n / 15
patients).
9) Abram pleural biopsies were performed in patients with
exudative pleural effusion and undiagnosed by routine pleural fluid
invistigations.
10) thoracoscopy in patients undiagnosed by Abram biopsy.
11) Exscional cervical lymph node biopsies in 4 cases presented by
cervical lymphadenopathy and sent for cytological examination.
Results:
(1) we have found that 16 patients ( 11.4% ) proved to have
pulmonary tuberculosis by + ve sputum ZN for acid fast bacilli and 28
patients (20%) were suspected to have pulmonary tuberculosis by
radiological suspesion and – ve sputum ZN for acid fast bacilli and 6
patients (4.3%) proved to have extra-pulmonary TB (Table5).
(2)The six patients with extra-pulmonary TB were diagnosed as TB
cervical lymphadenitis (2 patients) and TB pleural effusion (4 patients)
(table 6).
(3)There were no significant differences among different groups
with sputum ZN +ve but there were significant differences among
suspected cases (28) (P <0.05) as the numbers of suspected TB cases were more in group three in whom dialysis were performed for more than
one year (Table8).
(4) there were high significant differences among different groups
of pulmonary TB patients as regards, fever, haemoptysis and weight loss
as ( P<0.001) but there were non significant differences among the three
groups as regard cough. The most common symptom in group I were
weight loss followed by cough and haemoptysis. The most common
symptom in group II were fever followed by weight loss and cough. The
most common symptoms in group III were cough and haemoptysis
followed by weight loss and fever (Table 10).
(5)There were no significant difference among different groups of
patients with sputum ZN +ve as regards plain chest x-ray. In group I
there was one patient (16.6%) with normal plain chest x-ray , two patients
( 33.3%) with minimallesion ,two patients (33.3%) with moderate lesion
and one patient (16.6%) with far advanced lesion. In group II there were
two patients (50%) with minimal lesion and two patients (50%) with
moderate lesion. In group III there was one patient (16.6%) with normal
plain chest X ray , two patients ( 33.3%) with minimal lesion ,two
patients (33.3%) with moderate lesion and one patient (16.6%) with far
advanced lesion (table 14).
(6) There were no significant differences among different groups of
pulmonary tuberculosis patients as regards blood urea but there were
high significant differences (p <0.001) as regards serum creatinine levels
with the highest value in GIII (31.6±30) mg/dl ( table 17).