Improved Awareness of Tuberculosis Infection in Advanced Stage Chronic Renal Disease Could Reduce Cases of Active TB: Lessons from Four Challenging Cases

Patients with chronic kidney disease (CKD) have an increased risk of developing tuberculosis (TB) compared to those with normal renal function. The reasons for this are well described, but include impaired cellular immunity, a high incidence of co-morbid conditions as well as the concomitant use of immunosuppressive medications. Ethnicity as well as socio-economic factors also prevail. Expert guidelines recommend TB chemoprophylaxis in renal transplant recipients deemed at high risk – invariably those from ethnic minorities or recent arrivals from areas with high endemic rates of TB. However, in most renal centres within the UK including our own, high risk patients with advanced CKD (stages 4 and 5) are not routinely screened for latent TB infection (LTBI) prior to transplantation, thus contributing to missed opportunities for preventing TB disease. We report four challenging cases of patients diagnosed with TB disease on a background of advanced CKD, who all presented within an 18-month period whilst under the care of a large tertiary renal centre. Two of the cases were patients with well-functioning renal transplants and two were on renal replacement therapy. We describe our experience and share practical considerations on how to manage TB in CKD including the role of therapeutic drug monitoring in peritoneal dialysis. These cases highlight the need for a better awareness of the possibility of TB reactivation and underscore the arguments in favour of screening programmes for LTBI in patients with advanced CKD.