RESUMO
El riesgo de infección por Mycobacterium tuberculosis se halla aumentado en los pacientes con enfermedades inflamatorias crónicas y en tratamiento inmunosupresor, en particular con terapia antifactor de necrosis tumoral α. La detección de la infección tuberculosa latente y el tratamiento preventivo dirigido a reducir el riesgo de progresión a tuberculosis activa es obligatoria en este grupo de pacientes. Este documento de consenso multidisciplinar actualiza la opinión de expertos y establece recomendaciones para el diagnóstico y tratamiento de la infección tuberculosa latente en estos pacientes, según los conocimientos actuales en terapias biológicas
Patients with chronic inflammatory diseases being treated with immunosuppressive drugs, and with tumor necrosis factor inhibitors in particular, have an increased risk of infection by Mycobacterium tuberculosis. Screening for latent tuberculosis infection and preventive therapy to reduce the risk of progression to active tuberculosis are mandatory in this group of patients. This updated multidisciplinary consensus document presents the latest expert opinions on the treatment and prevention of tuberculosis in candidates for biologic therapy and establishes recommendations based on current knowledge relating to the use of biologic agents
Assuntos
Humanos , Antituberculosos/uso terapêutico , Tuberculose/prevenção & controle , Terapia Biológica/efeitos adversos , Anticorpos Monoclonais/efeitos adversos , Anticorpos Monoclonais/uso terapêutico , Antituberculosos/administração & dosagem , Hidradenite Supurativa/tratamento farmacológico , Seleção de Pacientes , Psoríase/tratamento farmacológico , Tuberculose/tratamento farmacológico , Monitoramento de Medicamentos , Fator de Necrose Tumoral alfa/antagonistas & inibidoresRESUMO
Patients with chronic inflammatory diseases being treated with immunosuppressive drugs, and with tumor necrosis factor inhibitors in particular, have an increased risk of infection by Mycobacterium tuberculosis. Screening for latent tuberculosis infection and preventive therapy to reduce the risk of progression to active tuberculosis are mandatory in this group of patients. This updated multidisciplinary consensus document presents the latest expert opinions on the treatment and prevention of tuberculosis in candidates for biologic therapy and establishes recommendations based on current knowledge relating to the use of biologic agents.
Assuntos
Antituberculosos/uso terapêutico , Terapia Biológica/efeitos adversos , Tuberculose Latente/tratamento farmacológico , Tuberculose/prevenção & controle , Anticorpos Monoclonais/efeitos adversos , Anticorpos Monoclonais/uso terapêutico , Antituberculosos/administração & dosagem , Monitoramento de Medicamentos , Hidradenite Supurativa/tratamento farmacológico , Humanos , Imunidade Celular , Tuberculose Latente/diagnóstico , Seleção de Pacientes , Psoríase/tratamento farmacológico , Risco , Subpopulações de Linfócitos T/imunologia , Tuberculose/tratamento farmacológico , Fator de Necrose Tumoral alfa/antagonistas & inibidoresRESUMO
BACKGROUND: Unlike conventional hemodialysis treatments, which rely almost solely on diffusion-related mechanisms for solute removal, hemodiafiltration (HDF) allows more efficient removal of higher molecular weight toxins due to convective transport mechanisms. To facilitate the removal of these toxins in HDF treatment modalities, dialyzers with highly efficient high-flux membranes are necessary. This study assessed the large uremic toxin removal ability of a high-flux dialyzer (FX CorDiax 60) specifically designed to facilitate convective therapies compared with a standard high-flux dialyzer (FX 60). METHODS: In an open, randomized, cross-over, single-center, controlled, prospective clinical study, 30 adult chronic hemodialysis patients were treated by post-dilution online HDF with the FX 60 or the FX CorDiax 60 dialyzer. All other dialysis parameters were kept constant in both study arms. The reduction rate (RR) of blood urea nitrogen, phosphate, ß2-microglobulin (ß2-m), myoglobin, prolactin, α1-microglobulin, α1-acid glycoprotein, albumin and total protein as well as the elimination into dialysate was intraindividually compared for the two dialyzer types. RESULTS: For FX CorDiax 60 versus FX 60, the RR was significantly higher for blood urea nitrogen (86.23 ± 4.14 vs. 84.89 ± 4.59%, p = 0.015), ß2-m (84.67 ± 3.79 vs. 81.30 ± 4.82%, p < 0.0001), myoglobin (75.23 ± 10.48 vs. 58.60 ± 12.1%, p < 0.0001), prolactin (72.96 ± 9.68 vs. 56.91 ± 13.01%, p < 0.0001) and α1-microglobulin (20.89 ± 18.27 vs. 13.60 ± 12.50%, p = 0.016). There were no significant differences in the RR for phosphate, α1-acid glycoprotein, albumin and total protein. Mass removal was significantly higher with the FX CorDiax 60 than with the FX 60 for ß2-m (0.26 ± 0.09 vs. 0.24 ± 0.09 g, p = 0.0006), myoglobin (1.83 ± 0.89 vs. 1.51 ± 0.76 mg, p = 0.0017), prolactin (0.17 ± 0.13 vs. 0.14 ± 0.08 mg, p = 0.02) and albumin (4.25 ± 3.49 vs. 3.01 ± 2.37 g, p = 0.03). CONCLUSIONS: This study demonstrates that treating patients with an FX CorDiax 60 instead of an FX 60 dialyzer in post-dilution HDF mode significantly increases the elimination of middle molecules.
Assuntos
Nitrogênio da Ureia Sanguínea , Hemodiafiltração , Falência Renal Crônica/sangue , Falência Renal Crônica/terapia , Idoso , Albuminas , alfa-Globulinas , Estudos Cross-Over , Feminino , Hemodiafiltração/efeitos adversos , Hemodiafiltração/instrumentação , Hemodiafiltração/métodos , Humanos , Falência Renal Crônica/etiologia , Masculino , Pessoa de Meia-Idade , Fosfatos/sangue , Resultado do Tratamento , Microglobulina beta-2/sangueRESUMO
We analysed the impact of the Xpert(®) MTB/RIF molecular test on health-care diagnostic delay among tuberculosis patients. Diagnostic delay was 17.2 days (standard deviation 23.2, median 10 days). Of 128 patients recruited into the study, 60 (47%) were smear-negative; of these, 40 (67%) were Xpert-positive and were started on treatment without culture. The sensitivity of smear microscopy was 53% compared with 82% for Xpert. In smear-negative patients, delay in Xpert-positive and -negative patients was respectively 15.5 ± 13.2 and 25.5 ± 12.5 days (P = 0.002). We conclude that Xpert results were significantly associated with shorter health-care diagnostic delay, particularly in smear-negative patients.
Assuntos
Técnicas Bacteriológicas , DNA Bacteriano/genética , Técnicas de Diagnóstico Molecular , Mycobacterium tuberculosis/genética , Tuberculose Pulmonar/diagnóstico , Adolescente , Adulto , DNA Bacteriano/isolamento & purificação , Diagnóstico Tardio , Feminino , Humanos , Masculino , Microscopia , Pessoa de Meia-Idade , Mycobacterium tuberculosis/isolamento & purificação , Valor Preditivo dos Testes , Estudos Retrospectivos , Escarro/microbiologia , Fatores de Tempo , Tuberculose Pulmonar/microbiologia , Adulto JovemAssuntos
Interferon gama/metabolismo , Falência Renal Crônica/complicações , Tuberculose Latente/diagnóstico , Terapia de Substituição Renal , Antígenos de Bactérias/imunologia , Emigrantes e Imigrantes , Europa (Continente)/epidemiologia , Reações Falso-Negativas , Humanos , Hospedeiro Imunocomprometido , Terapia de Imunossupressão/efeitos adversos , Incidência , Interferon gama/sangue , Falência Renal Crônica/imunologia , Falência Renal Crônica/terapia , Transplante de Rim , Tuberculose Latente/complicações , Tuberculose Latente/imunologia , Tuberculose Latente/microbiologia , Mycobacterium tuberculosis/imunologia , Mycobacterium tuberculosis/isolamento & purificação , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/imunologia , Prevalência , Terapia de Substituição Renal/estatística & dados numéricos , Risco , Sensibilidade e Especificidade , Teste TuberculínicoRESUMO
OBJECTIVE: The risk for tuberculosis (TB) is increased in patients with chronic renal failure and dialysis. Tuberculin skin test (TST) is the classical diagnostic method for screening despite its low sensitivity. New methods based on interferon-gamma have been developed. The aim of this study was to evaluate if Quantiferon® TB-gold In Tube (QFT-GIT) could be useful in the diagnosis of TB infection in patients on peritoneal dialysis (PD). PATIENTS AND METHODS: Fifty-four patients on PD were included in the study. They were evaluated for latent tuberculosis with QFT-GIT, TST and an assessment by an expert pulmonologist using patient's medical history and x-rays. Agreement between test results was determined. RESULTS: The prevalence of a positive TST was 29.6% for the first test and 31.5% for the second (booster effect). A positive chest x-ray increased the rate of detection of patients with latent TB infection up to 42.6% and the expert physician's evaluation to 44.4%. The correlation between QFT-GIT and TST was fair (k=0.36; P=.006), as it was between TST and expert physician's evaluation (k=0.257; P=.06). CONCLUSIONS: According to our experience QFT-GIT represents an important advantage in the diagnosis of latent TB infection in chronic renal failure patients on PD. It may complement but not replace TST.
Assuntos
Interferon gama/sangue , Falência Renal Crônica/complicações , Tuberculose Latente/diagnóstico , Diálise Peritoneal , Adulto , Idoso , Reações Falso-Negativas , Feminino , Humanos , Hospedeiro Imunocomprometido , Interferon gama/metabolismo , Falência Renal Crônica/imunologia , Falência Renal Crônica/terapia , Tuberculose Latente/sangue , Tuberculose Latente/complicações , Tuberculose Latente/diagnóstico por imagem , Ativação Linfocitária , Masculino , Programas de Rastreamento/métodos , Pessoa de Meia-Idade , Prevalência , Radiografia , Risco , Sensibilidade e Especificidade , Teste Tuberculínico , Tuberculose Pulmonar/diagnóstico por imagemRESUMO
Introducción: El riesgo de tuberculosis (TB) está aumentado en pacientes con insuficiencia renal crónica y en diálisis. La prueba de la tuberculina (PT) es el test de cribado clásico en estos pacientes, a pesar de su baja sensibilidad. En los últimos años se han desarrollado nuevos métodos diagnósticos que se basan en la producción de interferón gamma tras la estimulación con antígenos de M. tuberculosis. El objetivo de este estudio fue evaluar si el Quantiferon® TBgold In Tube (QFTGIT) puede contribuir en el diagnóstico de la infección tuberculosa en pacientes en diálisis peritoneal (DP). Pacientes y métodos: Se incluyeron 54 pacientes en DP. Se valoró la posibilidad de infección tuberculosa latente mediante el QFTGIT, la PT y la valoración clinicorradiológica por parte de un neumólogo experto. Se estudiaron las concordancias entre los tests. Resultados: La prevalencia de un resultado positivo para el test de la tuberculina fue del 29,6% para el primer test y del 31,5% para el segundo (valorando el efecto booster). Una radiografía de tórax positiva aumentaba la detección de infección tuberculosa latente hasta un 42,6% y la del neumólogo hasta un 44,4%. El nivel de correlación entre el QFTGIT y la PT fue moderado (kappa = 0,36; p = 0,006), al igual que entre la PT y la valoración del neumólogo (kappa = 0,257, p = 0,06). Conclusiones: El QFTGIT aporta algunas ventajas en el diagnóstico de la infección tuberculosa en pacientes con insuficiencia renal crónica en DP, y puede complementar a la prueba de la tuberculina (AU)
Objective: The risk for tuberculosis (TB) is increased in patients with chronic renal failure and dialysis. Tuberculin skin test (TST) is the classical diagnostic method for screening despite its low sensitivity. New methods based on interferongamma have been developed. The aim of this study was to evaluate if Quantiferon® TBgold In Tube (QFTGIT) could be useful in the diagnosis of TB infection in patients on peritoneal dialysis (PD). Patients and methods: Fiftyfour patients on PD were included in the study. They were evaluated for latent tuberculosis with QFTGIT, TST and an assessment by an expert pulmonologist using patient's medical history and xrays. Agreement between test results was determined. Results: The prevalence of a positive TST was 29.6% for the first test and 31.5% for the second (booster effect). A positive chest xray increased the rate of detection of patients with latent TB infection up to 42.6% and the expert physician's evaluation to 44.4%. The correlation between QFTGIT and TST was fair (ê=0.36; P=.006), as it was between TST and expert physician's evaluation (ê=0.257; P=.06). Conclusions: According to our experience QFTGIT represents an important advantage in the diagnosis of latent TB infection in chronic renal failure patients on PD. It may complement but not replace TST (AU)
Assuntos
Humanos , Diálise Peritoneal/métodos , Tuberculose Latente/diagnóstico , Teste Tuberculínico , Insuficiência Renal Crônica/complicações , Interferons/análise , Programas de Rastreamento/métodosRESUMO
The use of diagnostic techniques with iodinated contrast media represents a regular medical practice. Contrast induced nephropathy is a rare complication in the general population but it has an important prevalence and morbidity in selective groups of patients. Its multifactorial pathogenesis has not yet been totally determined. Identification of high-risk patients and early application of suitable preventive measures is crucial. The following article summarizes the most important aspects of this entity and the possibilities for its prevention.
Assuntos
Meios de Contraste/efeitos adversos , Nefropatias/induzido quimicamente , Nefropatias/prevenção & controle , Humanos , Fatores de RiscoRESUMO
La realización de pruebas diagnósticas concontrastes yodados representa una práctica habitualen medicina. La nefropatía por contraste constituyeuna complicación poco frecuente en la poblacióngeneral pero con importante prevalencia ymorbilidad en determinados grupos de pacientes. Supatogenia multifactorial no ha sido aúncompletamente esclarecida. La identificación de losenfermos con factores de riesgo y la aplicaciónprecoz de las oportunas medidas preventivas resultacrucial. El siguiente artículo resume los aspectosmás destacados de esta entidad y las posiblesestrategias profilácticas
The use of diagnostic techniques with iodinated contrastmedia represents a regular medical practice.Contrast induced nephropathy is a rare complicationin the general population but it has an importantprevalence and morbidity in selective groups ofpatients. Its multifactorial pathogenesis has not yetbeen totally determined. Identification of high-riskpatients and early application of suitable preventivemeasures is crucial. The following article summarizesthe most important aspects of this entity and the possibilities for its prevention (AU)