【文摘发布】如何最好地筛查血透患者中潜在的结核？
发布于 2007-05-31 · 浏览 1554 · IP 广东广东
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What is the best way of screening hemodialysis patients for latent tuberculosis?
Nature Clinical Practice Nephrology (2007) 3, 310-311
Background
The tuberculin skin test lacks sensitivity in patients on hemodialysis. A more reliable means of screening for latent tuberculosis in this setting is needed.
Objective
To compare the capacities of the tuberculin skin test, the interferon--based T-SPOT.TB assay (Oxford Immunotec, Oxford, UK), and an expert physician panel to diagnose latent tuberculosis in patients on hemodialysis.
Design and intervention
All consenting patients who received hemodialysis at the outpatient unit of Toronto General Hospital, ON, Canada, between 15 January and 15 April 2005 were prospectively enrolled. Evidence of active tuberculosis was an exclusion criterion. Each patient underwent T-SPOT.TB testing, tuberculin skin testing, and an interview to determine their history of or contact with active tuberculosis, Bacillus Calmette–Guérin vaccination status, occupational risk of tuberculosis and country of birth. Working independently, five physicians with experience of managing tuberculosis used information from the interview, tuberculin skin test and a recent chest radiograph (ideally from the preceding 6 months) to determine whether each participant had, or had previously had, tuberculosis. The final decision was by majority.
Outcome measure
Current or previous infection with Mycobacterium tuberculosis was the end point.
Results
The 203 patients studied comprised 71.0% of the 286 eligible patients. Current or previous tuberculosis was indicated in 72 (35.5%) of patients by the T-SPOT.TB test and in 26 (12.8%) of patients by the tuberculin skin test. The prevalence of current or previous infection determined by the physician panel was 26.1% (53 patients). Fourteen indeterminate results were obtained during the first round of T-SPOT.TB testing. Patients with a self-reported history of active tuberculosis (n = 14) had a positive T-SPOT.TB test result in 78.6% of cases; positive T-SPOT.TB test results were found for 72.7% of individuals with radiographic evidence of previous infection (n = 11) and for 73.1% of those with a positive tuberculin skin test (n = 26). The physician panel unanimously identified patients with any one of these three risk factors as infected. A positive tuberculin skin test result was obtained in 21.4% of the patients with a self-reported history of active tuberculosis, and in 18.2% of patients with radiographic evidence of previous infection. Multivariate logistic regression analysis revealed that a positive T-SPOT.TB test result correlated strongly with a self-reported history of active infection (odds ratio [OR] 7.24, 95% CI 1.70–30.8; P = 0.007), radiographic evidence of previous infection (OR 5.48, 95% CI 1.20–25.1; P = 0.03), and birth in a country with endemic tuberculosis (OR 5.45, 95% CI 2.72–10.9; P <0.0001). The T-SPOT.TB test had a relatively low level of agreement with the physician panel, as indicated by a kappa statistic of 0.37 (95% CI 0.24–0.50).
Conclusion
The tuberculin skin test should not be used alone to detect latent tuberculosis in hemodialysis patients; combined use of T-SPOT.TB testing and medical evaluation might offer greater accuracy.
Nature Clinical Practice Nephrology (2007) 3, 310-311
Background
The tuberculin skin test lacks sensitivity in patients on hemodialysis. A more reliable means of screening for latent tuberculosis in this setting is needed.
Objective
To compare the capacities of the tuberculin skin test, the interferon--based T-SPOT.TB assay (Oxford Immunotec, Oxford, UK), and an expert physician panel to diagnose latent tuberculosis in patients on hemodialysis.
Design and intervention
All consenting patients who received hemodialysis at the outpatient unit of Toronto General Hospital, ON, Canada, between 15 January and 15 April 2005 were prospectively enrolled. Evidence of active tuberculosis was an exclusion criterion. Each patient underwent T-SPOT.TB testing, tuberculin skin testing, and an interview to determine their history of or contact with active tuberculosis, Bacillus Calmette–Guérin vaccination status, occupational risk of tuberculosis and country of birth. Working independently, five physicians with experience of managing tuberculosis used information from the interview, tuberculin skin test and a recent chest radiograph (ideally from the preceding 6 months) to determine whether each participant had, or had previously had, tuberculosis. The final decision was by majority.
Outcome measure
Current or previous infection with Mycobacterium tuberculosis was the end point.
Results
The 203 patients studied comprised 71.0% of the 286 eligible patients. Current or previous tuberculosis was indicated in 72 (35.5%) of patients by the T-SPOT.TB test and in 26 (12.8%) of patients by the tuberculin skin test. The prevalence of current or previous infection determined by the physician panel was 26.1% (53 patients). Fourteen indeterminate results were obtained during the first round of T-SPOT.TB testing. Patients with a self-reported history of active tuberculosis (n = 14) had a positive T-SPOT.TB test result in 78.6% of cases; positive T-SPOT.TB test results were found for 72.7% of individuals with radiographic evidence of previous infection (n = 11) and for 73.1% of those with a positive tuberculin skin test (n = 26). The physician panel unanimously identified patients with any one of these three risk factors as infected. A positive tuberculin skin test result was obtained in 21.4% of the patients with a self-reported history of active tuberculosis, and in 18.2% of patients with radiographic evidence of previous infection. Multivariate logistic regression analysis revealed that a positive T-SPOT.TB test result correlated strongly with a self-reported history of active infection (odds ratio [OR] 7.24, 95% CI 1.70–30.8; P = 0.007), radiographic evidence of previous infection (OR 5.48, 95% CI 1.20–25.1; P = 0.03), and birth in a country with endemic tuberculosis (OR 5.45, 95% CI 2.72–10.9; P <0.0001). The T-SPOT.TB test had a relatively low level of agreement with the physician panel, as indicated by a kappa statistic of 0.37 (95% CI 0.24–0.50).
Conclusion
The tuberculin skin test should not be used alone to detect latent tuberculosis in hemodialysis patients; combined use of T-SPOT.TB testing and medical evaluation might offer greater accuracy.
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