What is the incidence of active tuberculosis in patients with chronic kidney disease, particularly in stages 3‑5, on dialysis, or after kidney transplantation?

Incidence of Tuberculosis in Chronic Kidney Disease Patients

Patients with chronic kidney disease have a dramatically elevated incidence of active tuberculosis, with rates ranging from 126 to 4200 per 100,000 patient-years depending on CKD stage and renal replacement therapy status, representing a 10-25 fold increased risk compared to the general population. 1

Incidence by CKD Stage and Treatment Modality

Advanced CKD (Stages 4-5)

• CKD stages 4-5 without dialysis carry an incidence rate ratio of 3.63 (95% CI: 2.25-5.86) compared to people without CKD 2
• The overall incidence in advanced CKD stages 4-5 reaches 256 per 100,000 patient-years 3
• Approximately 68.7% of TB cases in CKD patients occur in those with advanced disease (stages 4-5D) 4

Dialysis Patients

• Hemodialysis patients face the highest TB burden with an adjusted rate ratio of 3.62 (95% CI: 1.79-7.33) compared to the general population 5
• One UK study in a high-incidence area documented an incidence of 256 per 100,000 patient-years specifically in renal replacement therapy patients 3
• A tertiary care hospital in an endemic country reported an extraordinarily high incidence of 4200 per 100,000 among CKD patients with TB, with 20% on dialysis 4
• The prevalence of latent TB infection (LTBI) among dialysis patients is 25%, significantly higher than the 11% found in severe CKD patients not yet on dialysis 6

Early CKD (Stages 1-3)

• Early-stage CKD (stages 1-2) shows the lowest incidence rates within the CKD population 3
• Only 31.3% of TB cases in CKD patients occur in stages 1-3 4
• CKD stages 3-5 combined show a 57% increased risk (adjusted hazard ratio: 1.57; 95% CI: 1.22-2.03) compared to people without CKD 2

Kidney Transplant Recipients

• Transplant populations demonstrate an unadjusted risk ratio of 11.35 (95% CI: 2.97-43.41) compared to the general population 5
• Post-renal transplant CKD accounts for 3.5% of TB cases in the CKD population 4

Clinical Presentation Patterns in CKD-Associated TB

Extrapulmonary tuberculosis predominates in CKD patients, accounting for 75% of cases, which differs markedly from the general population where pulmonary disease is more common. 4

Site Distribution

• Pleuropulmonary involvement occurs in 41.8% of cases 4
• Kidney and urinary tract TB affects 20% 4
• Abdominal and lymph node involvement each account for 13% 4
• Only 48% present with pulmonary disease 3

Clinical Manifestations

• Fever or pyrexia of unknown origin: 24.3% 4
• Constitutional symptoms (anorexia, fever, night sweats, weight loss): 27.8% 4
• Abnormal chest radiograph: 31.2% 4
• Pleural effusion: 25.2% 4
• Lymphadenopathy: 20% 4
• Sterile pyuria/hematuria/chronic pyelonephritis: 13% 4
• Ascites/peritonitis: 13.9% 4

Risk Factors Within the CKD Population

Independent Predictors of Active TB

• Old age increases risk by 3% per year (OR: 1.03 per year increment; 95% CI: 1.01-1.04) 6
• Prior TB lesion on chest radiograph (OR: 2.90; 95% CI: 1.45-5.83) 6
• Higher serum albumin paradoxically predicts LTBI (OR: 2.59 per 1 g/dL increment; 95% CI: 1.63-4.11), likely reflecting better immune function to mount IGRA response 6
• Need for dialysis independently increases risk (OR: 2.47; 95% CI: 1.02-5.95) compared to severe CKD not yet on dialysis 6

Demographic Patterns

• 87% of TB cases in CKD patients occur in those of Asian/Asian British or Black/Black British ethnicity 3
• Mean age at TB diagnosis in CKD patients is 46.9 ± 16 years 4
• Male predominance: 53.9% of cases 4

Diagnostic Challenges

Microbiological or histopathological confirmation is achieved in only 45.2% of CKD patients with TB, necessitating clinical diagnosis in the majority (54.8%). 4

• Indeterminate IGRA results are more common in CKD patients with malignancy (OR: 4.91; 95% CI: 1.84-13.10) or low serum albumin (OR: 0.22 per 1 g/dL decrease; 95% CI: 0.10-0.51) 6
• The QFT-GIT interferon-gamma release assay response is similar across dialysis patients, severe CKD patients, and dialysis-unit staff 6

Treatment Outcomes and Adverse Effects

• 93% of CKD patients with TB complete treatment and survive 4
• Mortality rate is 7%, occurring exclusively in CKD stage 5D patients on dialysis 4
• Adverse effects from anti-TB drugs occur in 9.6% of CKD patients 4

Critical Clinical Pitfalls

TB cases occur steadily throughout the duration of renal replacement therapy, not just in the early period, mandating ongoing vigilance rather than one-time screening at dialysis initiation. 3

• The dialysis environment itself does not increase LTBI risk—dialysis-unit staff have only 11% LTBI prevalence, identical to severe CKD patients not on dialysis and lower than the 25% in dialysis patients 6
• The predominance of extrapulmonary disease means clinicians cannot rely solely on respiratory symptoms or chest radiographs for TB detection in CKD patients 4
• Constitutional symptoms are present in only 27.8% of cases, so their absence does not exclude TB 4