Incidence of Tuberculosis in Chronic Kidney Disease Patients
Patients with chronic kidney disease stages 3-5 and those on maintenance dialysis face a dramatically elevated tuberculosis incidence of 126-4,200 cases per 100,000 patient-years, representing a 10- to 25-fold increased risk compared to the general population. 1
Stage-Specific Incidence Rates
The tuberculosis incidence increases progressively with worsening kidney function:
- CKD stages 1-2: Baseline incidence similar to general population (approximately 10-15 per 100,000 person-years) 2
- CKD stage 3a: 168 per 100,000 person-years 2
- CKD stage 3b: 229 per 100,000 person-years 2
- CKD stage 4: 305 per 100,000 person-years 2
- CKD stage 5 (not on dialysis): 349 per 100,000 person-years 2
The risk escalates sharply beginning at CKD stage 3a, with a clear dose-response relationship as renal function deteriorates. 2
Dialysis Population Incidence
Patients receiving renal replacement therapy demonstrate particularly high tuberculosis rates:
- Hemodialysis patients: 1,267 per 100,000 patient-years (85-fold higher than UK background rate) 3
- Peritoneal dialysis patients: 398 per 100,000 patient-years (26-fold higher than UK background rate) 3
- Combined dialysis cohort: 256 per 100,000 patient-years 4
Interestingly, patients on long-term dialysis have a hazard ratio of 2.04 for tuberculosis development, which is similar to CKD stage 4 but lower than stage 5 CKD not yet on dialysis. 2 This suggests that dialysis may partially mitigate some immunologic dysfunction present in advanced uremia.
Latent Tuberculosis Infection Prevalence
Among dialysis patients screened with interferon-gamma release assay (IGRA), 25% tested positive for latent tuberculosis infection, significantly higher than the 11% prevalence in severe CKD patients (eGFR <30 mL/min not on dialysis) and 11% in dialysis-unit staff. 5 This indicates that the dialysis environment itself does not substantially increase transmission risk, but rather the immunocompromised state of dialysis patients drives their elevated tuberculosis susceptibility. 5
Clinical Presentation Patterns
The presentation of tuberculosis in CKD patients differs substantially from the general population:
- Pulmonary involvement: 48-63% of cases 3, 4
- Extrapulmonary disease: Highly prevalent, with tuberculous lymphadenitis and peritonitis being most common 6
- Tuberculous peritonitis: Comprises 37% of all tuberculosis cases in CAPD patients 6
- Symptomatology: Often insidious and nonspecific, mimicking uremic symptoms (anorexia, fever, weight loss) 6
Risk Factors Within CKD Population
Independent predictors of latent tuberculosis infection among patients with renal dysfunction include:
- Advanced age: Odds ratio 1.03 per year increment 5
- Prior tuberculosis lesion on chest radiograph: Odds ratio 2.90 5
- Higher serum albumin: Odds ratio 2.59 per 1 g/dL increment (paradoxically protective, likely reflecting better nutritional status) 5
- Need for dialysis: Odds ratio 2.47 compared to severe CKD not on dialysis 5
- Immunosuppression: 50% of CKD patients with tuberculosis had concurrent immunosuppression from medications, diabetes, or HIV 3
Temporal Patterns
The median time from CKD diagnosis to tuberculosis development is 12 months (range 0-192 months), with cases occurring steadily throughout the duration patients remain in advanced CKD or on dialysis. 3, 4 This persistent risk over time underscores that tuberculosis screening should not be a one-time event but rather considered periodically in high-risk CKD populations.
Ethnic and Geographic Considerations
In UK studies, 87% of tuberculosis cases in CKD patients occurred in individuals of Asian/Asian British or black/black British ethnicity, significantly higher than the ethnic distribution of the non-tuberculosis renal cohort. 4 Additionally, 65% of cases in one UK series were in non-UK born ethnic minorities from high-prevalence countries. 3
Drug Resistance Patterns
Among culture-positive tuberculosis cases in CKD patients, 25% had drug-resistant isolates, substantially higher than general population rates. 3 This finding emphasizes the importance of obtaining cultures and drug susceptibility testing in all CKD patients with suspected tuberculosis.
Clinical Implications
The American Thoracic Society and Centers for Disease Control and Prevention recognize that patients with renal insufficiency or end-stage renal disease are immunocompromised, and tuberculosis patients with chronic renal failure have worse clinical outcomes than those without renal failure. 7 The WHO guidelines for low tuberculosis burden countries recommend systematic testing and treatment of latent tuberculosis infection in patients receiving dialysis (strong recommendation). 7 The National Kidney Foundation states that chronic renal failure with hemodialysis carries 10-25 times greater tuberculosis risk than the general population. 8
Given the 6.9- to 52.5-fold increased tuberculosis risk in chronic renal failure and dialysis patients compared to the general population 6, and the incidence of 126 per 100,000 patient-years in advanced CKD rising to 1,267 per 100,000 patient-years in hemodialysis patients 1, 3, 4, clinicians must maintain high clinical suspicion for tuberculosis in any CKD patient presenting with nonspecific symptoms, particularly those from high-prevalence ethnic backgrounds or with additional immunosuppression.