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      Diagnosis and Treatment of Tuberculosis in Hemodialysis and Renal Transplant Patients

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          Background: The incidence of Mycobacterium tuberculosis in hemodialysis (HD) and renal transplant (RT) patients in developing countries is high. With the resurgence of tuberculosis in the US, insights gained in the diagnosis and treatment of this infection in HD and RT patients in developing countries should be valuable to physicians in the West. Methods: A retrospective study of 40 cases of tuberculosis, 24 in HD patients (24/177, 13.6%) and 16 in RT patients (16/109, 14.7%) diagnosed over a period of 21 months in one center. Results: The clinical features, diagnostic procedures, and management dilemmas of this group of patients are described in this report. Diabetes mellitus was the most common associated disease in both groups of patients. Fever, the most common presenting sign, was persistent low grade in 66.6% of HD patients and high intermittent in 56.2% of RT patients. Fever of unknown origin was only seen in RT patients. Pulmonary involvement was most common in both groups, presenting either as infiltrates or effusions. Tuberculous peritonitis was seen only in HD patients (33.3%). Eight HD patients were treated for tuberculosis for variable periods prior to transplantation, 4 of whom had less than 6 months of therapy. None had a recurrence of tuberculosis after transplantation. Because of the known cyclosporin-lowering effect of rifampicin resulting in an increased cost of immunosuppressive therapy, 13 patients were treated successfully with rifampicin-sparing therapy. Conclusion: Tuberculosis should be included in the differential diagnosis of fever in HD and RT patients, especially if fever is of unknown origin in the RT patient. M. tuberculosis in the renal transplant patient can present with high intermittent fever. Partial treatment of tuberculosis is sufficient prior to renal transplantation but treatment should be continued to completion after transplantation. If the cost of immunosuppressive therapy is prohibitive because of rifampicin, rifampicin-sparing antituberculosis therapy can be successfully employed in RT patients.

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          Exogenous reinfection with multidrug-resistant Mycobacterium tuberculosis in patients with advanced HIV infection.

          In the United States there have been recent outbreaks of multidrug-resistant tuberculosis. These outbreaks have primarily involved persons infected with the human immunodeficiency virus (HIV). We collected clinical information on 17 patients seen at a New York City hospital who had repeatedly positive cultures for Mycobacterium tuberculosis. Analysis of restriction-fragment--length polymorphisms (RFLPs) was performed on serial isolates of M. tuberculosis obtained from these patients. Six patients had isolates that remained drug-susceptible, and the RFLP patterns of these isolates did not change over time. Eleven patients had isolates that became resistant to antimicrobial agents. The RFLP patterns of the isolates from six of these patients remained essentially unchanged (two strains showed one additional band) despite the development of drug resistance. In five other patients, however, the RFLP patterns of the isolates changed dramatically at the time that drug resistance was detected. The change in the RFLP pattern of the isolate from one patient appeared to be the result of contamination during processing in the laboratory. In the remaining four patients, all of whom had advanced HIV disease, the clinical and microbiologic evidence was consistent with the presence of active tuberculosis caused by a new strain of M. tuberculosis. Resistance to antituberculous drugs can develop not only in the strain that caused the initial disease, but also as a result of reinfection with a new strain of M. tuberculosis that is drug-resistant. Exogenous reinfection with multidrug-resistant M. tuberculosis can occur either during therapy for the original infection or after therapy has been completed.
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            Mycobacterial infections in renal transplant recipients. Seven cases and a review of the literature.

            During an 11-year period, 1,069 patients received renal allografts at the University of Minnesota Hospital, Minneapolis, and infections developed in seven (0.65%) due to mycobacteria (Mycobacterium tuberculosis and M kansasii). The primary infection was in joint or subcutaneous tissue in six patients and pulmonary (miliary) in one. Infections in joint or skin shared common features regardless of the species of Mycobacterium and usually mimicked acute pyogenic bacterial infection; all responded to antimycobacterial drugs. The clinical manifestations in our patient in miliary tuberculosis were compared with those of 19 other patients described in the literature. Although their systemic manifestations were more severe, the symptoms were often ill-defined and the diagnosis overlooked. Five of these 20 patients (25%) died of uncontrolled infection.

              Author and article information

              Am J Nephrol
              American Journal of Nephrology
              S. Karger AG
              August 2000
              01 September 2000
              : 20
              : 4
              : 273-277
              aDivision of Renal Transplant, Bombay Hospital Institute of Medical Sciences, Mumbai, India, and bLouisiana State University Health Science Center, Shreveport, La., USA
              13600 Am J Nephrol 2000;20:273–277
              © 2000 S. Karger AG, Basel

              Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

              Page count
              Tables: 5, References: 13, Pages: 5
              Self URI (application/pdf):
              Clinical Study

              Cardiovascular Medicine, Nephrology

              Hemodialysis, Tuberculosis, Renal transplant


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