Screening for latent tuberculosis infection in patients with chronic kidney disease: a review of evidence and current practice in the UK.

Abstract

Tuberculosis (TB) and chronic kidney disease (CKD) represent an extant local and global syndemic, with TB incidence rates in the UK end-stage renal failure population far surpassing those of the general population in endemic countries. Patients with CKD generally have latent TB reactivation, rather than de novo infection, which presents with atypical, non-pulmonary presentations leading to late diagnosis, poorer outcomes and a high risk of widespread transmission through haemodialysis units. There is therefore a need to consider latent TB infection screening in the CKD population. However, there is widespread variation in local screening practices in the UK due to the challenge of diagnosing latent TB in CKD, and the absence of robust evidence-based guidelines. There is also concern that although a screening programme may have significant public health benefit, it may cause harm to the individual patient through adverse effects of treatment. In this review, we present the current evidence for latent TB infection screening in CKD, including the evidence of benefit and harm to the individual and the public. We also review current practices in the UK and present survey data from renal units in England demonstrating the diversity of policies currently in place. We advocate screening for latent TB in all CKD patients commencing dialysis and we highlight the pressing research questions that need to be urgently answered to help move towards a cohesive national policy to help drive evidence-based consistent care.