Tuberculosis in Dialysis Patients in the Central Region of Morocco: What Is the Health-Care Delay?

Abstract

Introduction: Due to the predominantly cellular immunosuppression, infections are frequent in chronic dialysis patients, in particular tuberculosis (TB). The main objective of our study is to evaluate tuberculosis healthcare delay in dialysis patients and to raise the diagnostic challenge in these patients.Material and methods: The study is retrospective and multicenter including tuberculosis cases of chronic dialysis patients either in hemodialysis (HD) or peritoneal dialysis (PD) in the central region of Morocco during a 10-year period between 2012 and 2021.Results: We included 94 patients, five of whom were in PD, with a mean age of 50.79 ± 16.72 years, and a sex ratio of 0.67. The time between the initiation of dialysis and the onset of the clinical and biological presentation was 50.3 ± 67.12 months. The most frequent initial manifestations were an alteration of the general state (85.1%), a biological inflammatory syndrome (83%) or a prolonged fever (70.1%). Among our 94 patients, the diagnosis was confirmed with bacteriological evidence only in 18 cases (19.1%), by identification of Koch's Bacillus (BK) in 13 cases, by molecular biology test (GeneXpert; Cepheid, Inc., Sunnyvale, CA, USA) in five cases. The diagnosis of tuberculosis was presumptive in most cases (79 cases), i.e. 80.9%. Twenty-one patients underwent the interferon gamma release essay test (QuantiFERON; Qiagen, Hilden, Germany) which was positive in 14 patients. Thirty-four (36.1%) cases had a histological diagnosis. The remaining patients were offered a trial treatment. Tuberculosis localization was mostly extra-pulmonary (75.5%): lymph node (23.4%), pleural (13.8%), peritoneal (13.8%), whereas it was pulmonary in 23 cases (24.5%).Most of our patients had a clear delay in management from symptom onset to initiation of anti-TB treatment 78.9% (time >21days) vs 21.1% (time ≤21days). The median time to management delay was 46.5 interquartile range (IQR) (28.5-90), the mean delay was 78.4 ± 87.9 (6-360). All patients were treated according to the RHZE/RH protocol (R: rifampicin, H: isoniazid Z: pyrazinamide and E: ethambutol), with a duration between six and 18 months. Side effects associated with anti-tuberculosis treatment were observed in half of the patients (51.1%). The evolution was favorable with remission and improvement of the general condition in 90% of cases. Two cases of resistance were noted in our series. The overall mortality was 7.7%.Conclusion: We have confirmed a delay in the diagnosis and treatment of tuberculosis in chronic dialysis patients. This can be explained by the often atypical or incomplete clinical and paraclinical presentation and the extra-pulmonary localizations, making diagnosis difficult in this population whose prognosis remains poor. It is therefore necessary to establish a diagnostic approach that is adapted to the specificities of these high-risk patients within the framework of a national tuberculosis control program.