الفهرس 
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Abstract
There is an increase in the incidence of TB during the last years for several factors, for these reasons the WHO declared TB a global emergency in 1993. In Egypt, tuberculosis is the second most important public health problem after bilharziasis. The rapid and accurate detection of mycobacterium tuberculosis are essential for treatment of infected patients and to control the spread of disease in population. The incidence of tuberculosis among uremic patients is 10 to 15 times higher than that of general population. Patients on dialysis should be considered a possible target population for evaluation for the presence of tuberculous infections. The aim of this work is to determine prevalence of tuberculosis among patients on haemodialysis. This study was conducted on 203 ESRD patients (134 males, 69 females) age range from 9-66 years. They were taken from outpatients of Nephrology and Urology Center, Mansoura University. They have been maintained on chronic haemodialysis programs in private, governmental and university hospitals. Patients were subjected to: - Through history taking, clinical and radiological examination. - Urine analysis for proteins, blood, glucose, cast and pus cells. - Urine culture on ordinary media. - Serum creatinine. - Electrolytes: serum sodium and potassium. - Fasting and two hours post prandial blood glucose. - Serum uric acid. - Serum calcium and phosphorus. - Liver function tests. - Erythrocyte sedimentation rate. - Complete blood picture. - Tuberculin test. - Dinitor chlorobenzen test for anergy detection. - ZN stain. - Culture by radiometric method (BACTEC). - Polymerase chain reaction. - Thoracocentesis. - Pleural biopsy. - Lymph node biopsy. Results from this study were: • Prevalence of tuberculosis in chronic renal failure patients on haemodialysis was 10.3%. • There was insignificant difference in mean age in tuberculous cases compared to non tuberculous cases (34.71 ± 14.19 and 36.46 ± 12.21 years respectively) (P > 0.05). • There was insignificant difference between males and females in tuberculous cases versus non tuberculous cases (P > 0.05). • Fever was significantly increased in tuberculous cases compared to non tuberculous cases (85.7%, 11.5% respectively x2 = 62.049, P < 0.05). • Night sweat was significantly increased in tuberculous cases compared to non tuberculous cases (66.7%, 4.9% respectively X2 = 65.382, P < 0.05). • Loss of weight was significantly increased in tuberculous cases compared to non tuberculous cases (38.1%, 3.3% respectively X2 = 30.295, P < 0.05). • Haemoptysis was significantly increased in tuberculous cases compared to non tuberculous cases (42.9%, 4.4% respectively X2 = 31.458, P < 0.05). • The mean duration of all symptoms was significantly increased in tuberculous cases compared to non tuberculous cases (5.76 ± 6.32, 1.07 ± 0.91weeks respectively P < 0.05). • Past history of tuberculosis was significantly increased in tuberculous cases compared to non tuberculous cases (23.8%, 1.1%, respectively X2 = 22.744, P < 0.05). • Abnormal findings in chest examination were significantly increased in tuberculous cases compared to non tuberculous cases (33.3%, 6% respectively X2 = 14.138, P < 0.05). • Abnormalities in x-ray chest were significantly increased in tuberculous cases compared to non tuberculous cases (33.3%, 3.3% respectively X2 = 23.550, P < 0.05). • Positive tuberculin test, (with cut off 10mm diameter) was significantly increased in tuberculous cases compared to non tuberculous cases (66.7%, 7.14%, respectively X2 = 45.584, P < 0.05). • 26.6% of patients were anergic and 13.3% were tuberculin reactors. • Mean ESR in first and second hours were significantly increased in tuberculous cases (101.24 ± 30.06, 128.90 ± 30.35 respectively) compared to non tuberculous cases (44.14% ± 16.13, 76.71 ± 19.08 respectively, P < 0.05). • Red blood cell count and haemoglobin concentration were significantly decreased in tuberculous cases (2.53 x 106 ± 0.63, 7.25 ± 1.61 respectively) compared to non tuberculous cases (3.02 x 106 ± 0.82, 8.52 ± 1.85 respectively, P < 0.05). • Microscopic haematuria was insignificantly increased in urinary tuberculosis compared to non tuberculous cases (87.5%, 86.96% respectively X2 = 0.002, P > 0.05). • Sterile pyuria was insignificantly increased in urinary tuberculosis compared to non tuberculous cases (100%, 86.96% respectively X2 = 0.145, P > 0.05). • There was highly significant good agreement between tuberculin test and BACTEC culture Kappa = 0.376, P < 0.05. • There was highly significant very good agreement between ZN and BACTEC culture Kappa = 0.894, P < 0.05. • There was highly significant very good agreement between PCR and BACTEC culture Kappa = 0.900, P < 0.05. • There was highly significant excellent agreement between pleural, lymph node biopsies and BACTEC culture Kappa = 1, P < 0.05. • The highest sensitivity was found in histopathological exmination of pleural and lymph node biopsies (100%) followed by PCR (95.24%) then ZN stain (85.71%) and lastly tuberculin test (66.67%). • The highest specificity was found in histopathological examination of pleural and lymph node biopsies, ZN stain (100% for each) followed by PCR (96%) and lastly tuberculin test (74%). • Positive predictive value, negative predictive value and accuracy varied in the laboratory test e.g., tuberculin test (51.85%, 84.09%, 71.83% respectively), ZN (100%, 94.34%, 95.77% respectively), PCR (90.91%, 97.96%, 95.77% respectively) and histopathological examination of pleural and lymph node biopsies (100%, 100%, 100% respectively). • From this study, it could be observed that the highest accuracy of diagnostic tests was found in histopathological examination of pleural and lymph node biopsies (100%) followed by PCR, ZN (95.77% for each) and lastly tuberculin test (71.83%). • The most frequent form of tuberculosis was extrapulmonary tuberculosis 57.14%. While pulmonary tuberculosis was found in 42.86%. • Tuberculosis was significantly increased in patients maintained on haemodialysis in private hospitals compared to patients maintained on haemodialysis in governmental and university hospitals (27.3%, 8.3% respectively X2 = 5.714, P < 0.05). • Tuberculosis was significantly decreased in patients maintained on haemodialysis in university hospitals compared to patients maintained on haemodialysis in private and governmental hospitals (2.4%, 16.1% respectively X2 = 10.070, P < 0.05). • There was insignificant difference between mean duration of dialysis in tuberculous cases compared to non tuberculous cases (20.05 ± 10.76, 26.72 ± 26.36 respectively, P > 0.05. • Diabetes mellitus and hepatitis B (especially if cirrhotic liver) were contributed to be major risk factor for TB in patients on haemodialysis. Conclusion and Recommendations: • High index of suspicion is required to recognize the presentation of tuberculosis that mimick the presentation of chronic renal failure in patients on haemodialysis. • Physical examination of the chest is important for detection of pulmonary tuberculosis in chronic renal failure patients on haemodialysis. So, routine examination of the chest is recommended for each patients. • Chest x-ray is an important screening test for detection of tuberculosis in chronic renal failure patients on haemodialysis. • Despite high rate of anergy in end stage renal disease, tuberculin test remains a useful test in evaluation of tuberculosis. BACTEC culture is recommended due to its high accuracy. It is considered a gold standard diagnostic method. • Histopathological examination if available simulate BACTEC culture in its accuracy. • The positivity of direct detection methods (ZN, culture, PCR) depend on the number of TB bacilli. As PCR (expensive) can detect few number, it could be restricted to specimens with scanty number of TB bacilli as in pleural effusion. While specimens which are expected to have high number of TB bacilli as in pulmonary tuberculosis ZN and culture have a diagnostic value. • Cultivation of mycobacterial tuberculosis from pleural tissue and histopathological examination of pleural biopsy should be done in each suspected case of tuberculous effusion to exclude atypical mycobacteria. • Diabetes mellitus and hepatitis B should be considered to be major risk factors for tuberculosis among patients on haemodialysis.