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Abstract 73 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 75 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). |