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Article(id=1211269038743876584, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1211269034906088369, articleNumber=null, orderNo=null, doi=10.11855/j.issn.0577-7402.2021.03.10, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=research-article, receivedDate=1608912000000, receivedDateStr=2020-12-26, revisedDate=1613836800000, revisedDateStr=2021-02-21, acceptedDate=null, acceptedDateStr=null, onlineDate=1766718643127, onlineDateStr=2025-12-26, pubDate=1616860800000, pubDateStr=2021-03-28, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1766718643127, onlineIssueDateStr=2025-12-26, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1766718643127, creator=13701087609, updateTime=1766718643127, updator=13701087609, issue=Issue{id=1211269034906088369, tenantId=1146029695717560320, journalId=1189873630562394117, year='2021', volume='46', issue='3', pageStart='213', pageEnd='318', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=0, createTime=1766718642212, creator=13701087609, updateTime=1766718779849, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1211269612247838856, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1211269034906088369, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1211269612247838857, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1211269034906088369, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=274, endPage=279, ext={EN=ArticleExt(id=1211269039012312058, articleId=1211269038743876584, tenantId=1146029695717560320, journalId=1189873630562394117, language=EN, title=Clinical analysis of pulmonary tuberculosis and extrapulmonary tuberculosis complicated in maintenance hemodialysis patients with end-stage renal disease, columnId=1190310109000602400, journalTitle=Medical Journal of Chinese People’s Liberation Army, columnName=Clinical Research, runingTitle=null, highlight=null, articleAbstract=

Objective To explore the clinical features of patients with end-stage renal disease (ESRD) complicated with pulmonary tuberculosis (PTB) and extrapulmonary tuberculosis (EPTB) and undergoing maintenance hemodialysis (MHD). Methods A total of 133 ESRD patients complicated with tuberculosis, treated at the Tuberculosis Department of the 8th Medical Center of Chinese PLA General Hospital and undergoing MHD at the Blood Purification Center, were selected from July 2012 to February 2021, and divided into PTB group (87 cases) and EPTB group (46 cases). The clinical characteristics, treatment and prognosis of the two groups were compared and analyzed. Results Both PTB group and EPTB group were predominantly male patients (80.5% and 58.7%), but the proportion of female patients was higher in EPTB group (41.3%) than that in PTB group (19.5%, P<0.05). No significant differences existed between the two groups in age, primary kidney disease, comorbidities, dialysis duration, and the detection time-point of tuberculosis after dialysis. Among the first symptoms, the proportion of cough+sputum and fever was significantly higher in PTB group than that in EPTB group (59.8% vs. 23.9% and 60.9% vs. 28.3%, respectively, P<0.05), while the proportion of pain at lesion location was significantly lower in PTB group than that in EPTB group (8.0% vs. 41.3%, P<0.05).CT or MRI imaging was the dominated method for definite diagnosis in both PTB group and EPTB group (67.8% and 76.1%), the secondary method was sputum smear or culture (26.4% and 6.5%) and needle biopsy (5.7% and 17.4%), respectively, with a significant difference between the two groups (P<0.05). No significant difference existed in the positive rate of γ-interferon release assay (γ-IRA) between the two groups. In both PTB group and EPTB group, the proportion of lymphocytes, hemoglobin and albumin decreased markedly, while the proportion of erythrocyte sedimentation rate (ESR) and increased C-reactive protein(CRP) were relatively higher, but there was no statistical difference between the two groups. Both groups were treated with anti-tuberculosis drugs, and one case in EPTB group received anti-tuberculosis drugs plus surgery of tuberculosis focus clearance. No significant difference existed in the incidence of adverse reactions between the two groups, and the improvement rate after treatment was similar. Conclusions Significant differences exist between PTB and EPTB patients with ESRD on MHD in gender ratio, first manifested symptom and diagnosis methods. Paying attention to these differences and conducting individualized monitoring, diagnosis and treatment will be helpful to reduce the morbidity and mortality of patients with PTB and EPTB.

, correspAuthors=Wu-Xing Zhang, authorNote=null, correspAuthorsNote=
*E-mail:
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目的 探讨终末期肾病维持性血液透析患者并发肺结核(PTB)和肺外结核(EPTB)的临床特点。方法 选择2012年7月—2021年2月在解放军总医院第八医学中心结核科就诊并在血液净化中心行维持性血液透析治疗的终末期肾病并发结核病患者共133例，分为PTB组(n=87)与EPTB组(n=46)，对比分析两组患者的临床特点及预后情况。结果 PTB组及EPTB组均以男性为主(80.5% vs. 58.7%)，但EPTB组的女性比例(41.3%)较PTB组(19.5%)更高(P<0.05)。两组的年龄、肾脏原发病、合并疾病、透析时间、透析后结核检出时间差异无统计学意义。出现的首发症状中，PTB组咳嗽咳痰(59.8%)及发热(60.9%)比例明显高于EPTB组(分别为23.9%、28.3%，P<0.05)，而病变部位疼痛比例明显低于EPTB组(8.0% vs. 41.3%，P<0.05)。PTB组及EPTB组的确诊方式均以CT或MRI影像学检查为主(67.8% vs. 76.1%)，其次分别为痰涂片或培养(26.4% vs. 6.5%)及穿刺活检(5.7% vs. 17.4%)，两组间差异均有统计学意义(P<0.05)。两组γ干扰素释放试验阳性率差异无统计学意义。PTB组与EPTB组中淋巴细胞、血红蛋白、白蛋白降低的比例，以及红细胞沉降率、C-反应蛋白升高的比例均较高，但组间差异无统计学意义。两组均行抗结核药物治疗，EPTB组1例在抗结核药物治疗的基础上行结核灶清除手术治疗。两组不良反应发生率差异无统计学意义，治疗好转率相似。结论 终末期肾病维持性血液透析的PTB与EPTB患者在性别比例、首发症状及确诊方式方面存在明显差异，重视这些差异，进行个体化监测和诊治，将有助于降低PTB及EPTB的发病率及病死率。

, correspAuthors=张五星, authorNote=null, correspAuthorsNote=
张五星，E-mail：
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任瑞霖，硕士研究生，主要从事肾脏病与血液透析方面的研究。E-mail：

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任瑞霖，硕士研究生，主要从事肾脏病与血液透析方面的研究。E-mail：

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任瑞霖，硕士研究生，主要从事肾脏病与血液透析方面的研究。E-mail：

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Chin J Blood Purif, 2016, 15(11): 577-586., articleTitle=Chinese expert consensus on the management of adult patients with chronic kidney disease and tuberculosis, refAbstract=null), Reference(id=1211269050131411342, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1211269038743876584, doi=null, pmid=null, pmcid=null, year=2016, volume=15, issue=11, pageStart=577, pageEnd=586, url=null, language=null, rfNumber=[30], rfOrder=34, authorNames=李洪, journalName=中国血液净化, refType=null, unstructuredReference=[李洪. 中国成人慢性肾脏病合并结核病管理专家共识[J]. 中国血液净化, 2016, 15(11): 577-586.], articleTitle=中国成人慢性肾脏病合并结核病管理专家共识, refAbstract=null)], funds=null, companyList=[AuthorCompany(id=1211269039557570598, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1211269038743876584, xref=1, ext=[AuthorCompanyExt(id=1211269039565959206, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1211269038743876584, companyId=1211269039557570598, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=1Graduate School of Hebei North University, Zhangjiakou, Hebei 075000, China), AuthorCompanyExt(id=1211269039574347815, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1211269038743876584, companyId=1211269039557570598, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=1河北北方学院研究生院，河北 张家口 075000)]), AuthorCompany(id=1211269039633068076, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1211269038743876584, xref=2, ext=[AuthorCompanyExt(id=1211269039641456684, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1211269038743876584, companyId=1211269039633068076, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=2Department of Nephrology, the 8th Medical Center of Chinese PLA General Hospital, Beijing 100091, China), AuthorCompanyExt(id=1211269039645650989, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1211269038743876584, companyId=1211269039633068076, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=2解放军总医院第八医学中心肾内科，北京 100091)])], figs=[ArticleFig(id=1211269043252752597, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1211269038743876584, language=EN, label=Tab.1, caption=

Comparison of general information between PTB group and EPTB group [n(%)]

, figureFileSmall=null, figureFileBig=null, tableContent=
项目PTB组(n=87)EPTB组(n=46)P
男/女(例)70/1727/190.007
年龄(岁，$\bar{x}±s$)53.4±16.254.6±13.30.681
原发病[例(%)]  0.751
 原发性肾小球肾炎64(73.6)35(76.1)
 其他23(26.4)11(23.9)
合并疾病[例(%)]
 高血压64(73.6)32(69.6)0.625
 糖尿病35(40.2)21(45.7)0.547
 冠心病16(18.4)4(8.7)0.218
透析时间[例(%)]  0.452
 ≤1年32(36.8)20(43.5)
 >1年55(63.2)26(56.5)
结核检出时间[例(%)]  0.534
 透析后≤1年33(37.9)20(43.5)
 透析后>1年54(62.1)26(56.5) 
), ArticleFig(id=1211269043349221593, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1211269038743876584, language=CN, label=表1, caption=

PTB组与EPTB组一般资料比较[例(%)]

, figureFileSmall=null, figureFileBig=null, tableContent=
项目PTB组(n=87)EPTB组(n=46)P
男/女(例)70/1727/190.007
年龄(岁，$\bar{x}±s$)53.4±16.254.6±13.30.681
原发病[例(%)]  0.751
 原发性肾小球肾炎64(73.6)35(76.1)
 其他23(26.4)11(23.9)
合并疾病[例(%)]
 高血压64(73.6)32(69.6)0.625
 糖尿病35(40.2)21(45.7)0.547
 冠心病16(18.4)4(8.7)0.218
透析时间[例(%)]  0.452
 ≤1年32(36.8)20(43.5)
 >1年55(63.2)26(56.5)
结核检出时间[例(%)]  0.534
 透析后≤1年33(37.9)20(43.5)
 透析后>1年54(62.1)26(56.5) 
), ArticleFig(id=1211269043428913374, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1211269038743876584, language=EN, label=Tab.2, caption=

Comparison of first manifested symptoms between PTB group and EPTB group [n(%)]

, figureFileSmall=null, figureFileBig=null, tableContent=
首发症状PTB组(n=87)EPTB组(n=46)P
发热53(60.9)13(28.3)0.000
咳嗽、咳痰52(59.8)11(23.9)0.000
胸闷19(21.8)8(17.4)0.544
疼痛7(8.0)19(41.3)0.000
乏力、纳差6(6.9)6(13.0)0.239
腹胀1(1.1)4(8.7)0.090
), ArticleFig(id=1211269043512799457, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1211269038743876584, language=CN, label=表2, caption=

PTB组与EPTB组首发症状比较[例(%)]

, figureFileSmall=null, figureFileBig=null, tableContent=
首发症状PTB组(n=87)EPTB组(n=46)P
发热53(60.9)13(28.3)0.000
咳嗽、咳痰52(59.8)11(23.9)0.000
胸闷19(21.8)8(17.4)0.544
疼痛7(8.0)19(41.3)0.000
乏力、纳差6(6.9)6(13.0)0.239
腹胀1(1.1)4(8.7)0.090
), ArticleFig(id=1211269043596685544, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1211269038743876584, language=EN, label=Tab.3, caption=

Comparison of diagnostic methods between PTB group and EPTB group [n(%)]

, figureFileSmall=null, figureFileBig=null, tableContent=
诊断方式PTB组(n=87)EPTB组(n=46)P
痰结核分枝杆菌培养a  0.038
 阳性23(29.5)3(9.1)
 阴性55(70.5)30(90.9)
γ干扰素释放试验b  0.728
 阳性38(58.5)22(55.0)
 阴性27(41.5)18(45.0)
确诊方式  0.005
 CT或MRI59(67.8)35(76.1)
 穿刺活检5(5.7)8(17.4)
 痰涂片或培养23(26.4)3(6.5) 
), ArticleFig(id=1211269043680571628, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1211269038743876584, language=CN, label=表3, caption=

PTB组与EPTB组诊断方式比较[例(%)]

, figureFileSmall=null, figureFileBig=null, tableContent=
诊断方式PTB组(n=87)EPTB组(n=46)P
痰结核分枝杆菌培养a  0.038
 阳性23(29.5)3(9.1)
 阴性55(70.5)30(90.9)
γ干扰素释放试验b  0.728
 阳性38(58.5)22(55.0)
 阴性27(41.5)18(45.0)
确诊方式  0.005
 CT或MRI59(67.8)35(76.1)
 穿刺活检5(5.7)8(17.4)
 痰涂片或培养23(26.4)3(6.5) 
), ArticleFig(id=1211269043772846319, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1211269038743876584, language=EN, label=Tab.4, caption=

Comparison of serological results between PTB group and EPTB group [n(%)]

, figureFileSmall=null, figureFileBig=null, tableContent=
指标PTB组(n=87)EPTB组(n=46)P
升高正常降低升高正常降低
白细胞14(16.1)62(71.3)11(12.6)9(19.6)32(69.6)5(10.9)0.860
中性粒细胞23(26.4)61(70.1)3(3.4)14(30.4)29(63.0)3(6.5)0.599
淋巴细胞040(46.0)47(54.0)025(54.3)21(45.7)0.358
血红蛋白1(1.1)15(17.2)71(81.6)09(19.6)37(80.4)0.732
白蛋白028(32.2)59(67.8)014(30.4)32(69.6)0.836
红细胞沉降率a74(86.0)12(14.0)040(88.9)5(11.1)00.646
ADAb21(42.0)27(54.0)2(4.0)8(30.8)15(57.7)3(11.5)0.353
CRPc78(92.9)6(7.1)038(84.4)7(15.6)00.130
), ArticleFig(id=1211269043886092532, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1211269038743876584, language=CN, label=表4, caption=

PTB组与EPTB组血清学检查结果比较[例(%)]

, figureFileSmall=null, figureFileBig=null, tableContent=
指标PTB组(n=87)EPTB组(n=46)P
升高正常降低升高正常降低
白细胞14(16.1)62(71.3)11(12.6)9(19.6)32(69.6)5(10.9)0.860
中性粒细胞23(26.4)61(70.1)3(3.4)14(30.4)29(63.0)3(6.5)0.599
淋巴细胞040(46.0)47(54.0)025(54.3)21(45.7)0.358
血红蛋白1(1.1)15(17.2)71(81.6)09(19.6)37(80.4)0.732
白蛋白028(32.2)59(67.8)014(30.4)32(69.6)0.836
红细胞沉降率a74(86.0)12(14.0)040(88.9)5(11.1)00.646
ADAb21(42.0)27(54.0)2(4.0)8(30.8)15(57.7)3(11.5)0.353
CRPc78(92.9)6(7.1)038(84.4)7(15.6)00.130
), ArticleFig(id=1211269044066447607, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1211269038743876584, language=EN, label=Tab.5, caption=

Comparison of treatment and outcome between PTB group and EPTB group [n(%)]

, figureFileSmall=null, figureFileBig=null, tableContent=
指标PTB组(n=87)EPTB组(n=46)P
治疗方案  0.167
 抗结核87(100.0)45(97.8)
 抗结核+结核病灶清除术01(2.2)
不良反应  0.495
 发生13(14.9)9(19.6)
 未发生74(85.1)37(80.4)
转归  0.170
 好转81(93.1)43(93.5)
 加重4(4.6)0
 死亡2(2.3)3(6.5) 
), ArticleFig(id=1211269044167110910, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1211269038743876584, language=CN, label=表5, caption=

PTB组与EPTB组治疗及转归情况比较[例(%)]

, figureFileSmall=null, figureFileBig=null, tableContent=
指标PTB组(n=87)EPTB组(n=46)P
治疗方案  0.167
 抗结核87(100.0)45(97.8)
 抗结核+结核病灶清除术01(2.2)
不良反应  0.495
 发生13(14.9)9(19.6)
 未发生74(85.1)37(80.4)
转归  0.170
 好转81(93.1)43(93.5)
 加重4(4.6)0
 死亡2(2.3)3(6.5) 
), ArticleFig(id=1211269044292940032, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1211269038743876584, language=EN, label=Tab.6, caption=

Comparison of adverse reactions between PTB group and EPTB group [n(%)]

, figureFileSmall=null, figureFileBig=null, tableContent=
不良反应PTB组(n=87)EPTB组(n=46)P
双下肢麻木3(3.4)3(6.5)0.709
视物模糊5(5.7)1(2.2)0.613
消化道反应2(2.3)2(4.3)0.901
肝功能异常3(3.4)1(2.2)1.000
白细胞减少2(2.3)00.544
血小板减少1(1.1)2(4.3)0.570
皮疹1(1.1)01.000
), ArticleFig(id=1211269045496705289, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1211269038743876584, language=CN, label=表6, caption=

PTB组与EPTB组不良反应比较[例(%)]

, figureFileSmall=null, figureFileBig=null, tableContent=
不良反应PTB组(n=87)EPTB组(n=46)P
双下肢麻木3(3.4)3(6.5)0.709
视物模糊5(5.7)1(2.2)0.613
消化道反应2(2.3)2(4.3)0.901
肝功能异常3(3.4)1(2.2)1.000
白细胞减少2(2.3)00.544
血小板减少1(1.1)2(4.3)0.570
皮疹1(1.1)01.000
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终末期肾病维持性血液透析患者并发肺结核与肺外结核的临床特点
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任瑞霖 1 , 张五星 2, * , 周伟 2 , 汪杨 2 , 黄巍 2
解放军医学杂志 | 临床研究 2021,46(3): 274-279
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解放军医学杂志 | 临床研究 2021, 46(3): 274-279
终末期肾病维持性血液透析患者并发肺结核与肺外结核的临床特点
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任瑞霖1 , 张五星2, * , 周伟2, 汪杨2, 黄巍2
作者信息
  • 1河北北方学院研究生院，河北 张家口 075000
  • 2解放军总医院第八医学中心肾内科，北京 100091

    • 任瑞霖，硕士研究生，主要从事肾脏病与血液透析方面的研究。E-mail：

通讯作者:

张五星，E-mail：
Clinical analysis of pulmonary tuberculosis and extrapulmonary tuberculosis complicated in maintenance hemodialysis patients with end-stage renal disease
Rui-Lin Ren1 , Wu-Xing Zhang2, * , Wei Zhou2, Yang Wang2, Wei Huang2
Affiliations
  • 1Graduate School of Hebei North University, Zhangjiakou, Hebei 075000, China
  • 2Department of Nephrology, the 8th Medical Center of Chinese PLA General Hospital, Beijing 100091, China
出版时间: 2021-03-28 doi: 10.11855/j.issn.0577-7402.2021.03.10
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摘要
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目的 探讨终末期肾病维持性血液透析患者并发肺结核(PTB)和肺外结核(EPTB)的临床特点。方法 选择2012年7月—2021年2月在解放军总医院第八医学中心结核科就诊并在血液净化中心行维持性血液透析治疗的终末期肾病并发结核病患者共133例，分为PTB组(n=87)与EPTB组(n=46)，对比分析两组患者的临床特点及预后情况。结果 PTB组及EPTB组均以男性为主(80.5% vs. 58.7%)，但EPTB组的女性比例(41.3%)较PTB组(19.5%)更高(P<0.05)。两组的年龄、肾脏原发病、合并疾病、透析时间、透析后结核检出时间差异无统计学意义。出现的首发症状中，PTB组咳嗽咳痰(59.8%)及发热(60.9%)比例明显高于EPTB组(分别为23.9%、28.3%，P<0.05)，而病变部位疼痛比例明显低于EPTB组(8.0% vs. 41.3%，P<0.05)。PTB组及EPTB组的确诊方式均以CT或MRI影像学检查为主(67.8% vs. 76.1%)，其次分别为痰涂片或培养(26.4% vs. 6.5%)及穿刺活检(5.7% vs. 17.4%)，两组间差异均有统计学意义(P<0.05)。两组γ干扰素释放试验阳性率差异无统计学意义。PTB组与EPTB组中淋巴细胞、血红蛋白、白蛋白降低的比例，以及红细胞沉降率、C-反应蛋白升高的比例均较高，但组间差异无统计学意义。两组均行抗结核药物治疗，EPTB组1例在抗结核药物治疗的基础上行结核灶清除手术治疗。两组不良反应发生率差异无统计学意义，治疗好转率相似。结论 终末期肾病维持性血液透析的PTB与EPTB患者在性别比例、首发症状及确诊方式方面存在明显差异，重视这些差异，进行个体化监测和诊治，将有助于降低PTB及EPTB的发病率及病死率。

终末期肾病  /  维持性血液透析  /  肺结核  /  肺外结核

Objective To explore the clinical features of patients with end-stage renal disease (ESRD) complicated with pulmonary tuberculosis (PTB) and extrapulmonary tuberculosis (EPTB) and undergoing maintenance hemodialysis (MHD). Methods A total of 133 ESRD patients complicated with tuberculosis, treated at the Tuberculosis Department of the 8th Medical Center of Chinese PLA General Hospital and undergoing MHD at the Blood Purification Center, were selected from July 2012 to February 2021, and divided into PTB group (87 cases) and EPTB group (46 cases). The clinical characteristics, treatment and prognosis of the two groups were compared and analyzed. Results Both PTB group and EPTB group were predominantly male patients (80.5% and 58.7%), but the proportion of female patients was higher in EPTB group (41.3%) than that in PTB group (19.5%, P<0.05). No significant differences existed between the two groups in age, primary kidney disease, comorbidities, dialysis duration, and the detection time-point of tuberculosis after dialysis. Among the first symptoms, the proportion of cough+sputum and fever was significantly higher in PTB group than that in EPTB group (59.8% vs. 23.9% and 60.9% vs. 28.3%, respectively, P<0.05), while the proportion of pain at lesion location was significantly lower in PTB group than that in EPTB group (8.0% vs. 41.3%, P<0.05).CT or MRI imaging was the dominated method for definite diagnosis in both PTB group and EPTB group (67.8% and 76.1%), the secondary method was sputum smear or culture (26.4% and 6.5%) and needle biopsy (5.7% and 17.4%), respectively, with a significant difference between the two groups (P<0.05). No significant difference existed in the positive rate of γ-interferon release assay (γ-IRA) between the two groups. In both PTB group and EPTB group, the proportion of lymphocytes, hemoglobin and albumin decreased markedly, while the proportion of erythrocyte sedimentation rate (ESR) and increased C-reactive protein(CRP) were relatively higher, but there was no statistical difference between the two groups. Both groups were treated with anti-tuberculosis drugs, and one case in EPTB group received anti-tuberculosis drugs plus surgery of tuberculosis focus clearance. No significant difference existed in the incidence of adverse reactions between the two groups, and the improvement rate after treatment was similar. Conclusions Significant differences exist between PTB and EPTB patients with ESRD on MHD in gender ratio, first manifested symptom and diagnosis methods. Paying attention to these differences and conducting individualized monitoring, diagnosis and treatment will be helpful to reduce the morbidity and mortality of patients with PTB and EPTB.

end-stage renal disease  /  maintenance hemodialysis  /  pulmonary tuberculosis  /  extrapulmonary tuberculosis
任瑞霖, 张五星, 周伟, 汪杨, 黄巍. 终末期肾病维持性血液透析患者并发肺结核与肺外结核的临床特点. 解放军医学杂志, 2021 , 46 (3) : 274 -279 . DOI: 10.11855/j.issn.0577-7402.2021.03.10
Rui-Lin Ren, Wu-Xing Zhang, Wei Zhou, Yang Wang, Wei Huang. Clinical analysis of pulmonary tuberculosis and extrapulmonary tuberculosis complicated in maintenance hemodialysis patients with end-stage renal disease[J]. Medical Journal of Chinese People’s Liberation Army, 2021 , 46 (3) : 274 -279 . DOI: 10.11855/j.issn.0577-7402.2021.03.10
正文
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结核病属于全球公共卫生问题，发病率及死亡率均较高[1]，估计每年发病率为183/10万[2]。其中肺结核(pulmonary tuberculosis，PTB)最常见[3]，但也常表现为肺外结核(extrapulmonary tuberculosis，EPTB)[4]。行维持性血液透析(maintenance hemodialysis，MHD)的终末期肾病(end-stage renal disease，ESRD)患者，由于免疫功能受损、高龄、糖尿病、营养不良及频繁出入医院等原因，结核发病率远高于普通人群，在临床表现、诊断及治疗方面也有其特殊性[5-6]。目前，针对普通人群PTB及EPTB的流行病学、诊断及治疗已有较多研究，证实EPTB在年轻人、女性中发病率较高[7-8]，PTB及EPTB在首发症状及确诊方式等方面也存在不同[9-10]，抗结核治疗后均可好转[11]。但在行MHD的ESRD人群中，PTB与EPTB的比较尚未见报道。本研究对133例行MHD的ESRD并发PTB或EPTB患者的临床特点及预后情况进行比较分析，旨在进一步提高对此类患者的认识。
1 资料与方法
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1.1 研究对象
回顾性分析2012年7月—2021年2月在解放军总医院第八医学中心结核科就诊并在血液净化中心行MHD治疗的ESRD患者4061例，其中男2786例(68.6%)，女1275例(31.4%)，年龄(47.8±16.1)岁。从中筛选出并发结核病的患者133例(3.3%)，其中PTB患者87例，EPTB患者46例。纳入标准：(1)行MHD的ESRD患者；(2)透析时间在3个月以上；(3)透析前无结核病史及活动性结核表现；(4)符合结核病的诊断标准。结核病的诊断标准为：除存在结核病相应的临床表现外，必须具备下列表现中的1项以上：(1)病原学检出病原菌；(2)病理学证实为结核；(3)不明原因发热1个月以上，正规抗生素治疗无效，抗结核药物治疗数天后症状明显好转[12]。EPTB的诊断标准：参照2017年《中华人民共和国卫生行业标准(结核病分类)》定义，即结核病变发生在肺以外的器官和组织，如淋巴结(除外胸内淋巴结)、骨、关节、泌尿生殖系统、消化系统、中枢神经系统等。本研究已通过解放军总医院第八医学中心伦理委员会的审查和批准。
1.2 观察指标
记录并比较行MHD的ESRD且并发PTB或EPTB患者的性别、年龄、原发病、并存疾病、透析时间、透析后结核检出时间、首发症状、结核部位、确诊方式等一般情况，并对患者的实验室检查结果如痰结核杆菌培养、白细胞计数、中性粒细胞、淋巴细胞、血红蛋白、血浆白蛋白(albumin，Alb)、γ干扰素释放试验、红细胞沉降率、C反应蛋白(C-reactive protein，CRP)、腺苷酸脱氨酶(adenosine deaminase，ADA)，以及影像学检查、治疗方案、药物不良反应及预后情况等进行比较。
1.3 统计学处理
采用SPSS 25.0软件进行统计分析。计量资料以$\bar{x}±s$表示，两组间比较采用t检验；计数资料以例(%)表示，两组间比较采用χ2检验或Fisher确切概率法。P<0.05为差异有统计学意义。
2 结果
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2.1 一般资料比较
PTB组及EPTB组均以男性为主，但EPTB组的女性比例较PTB组更高(P<0.05)。两组的年龄、肾脏原发病、合并疾病、透析时间、透析后结核检出时间差异均无统计学意义。两组均以中老年人为主，肾脏原发病均以原发性肾小球肾炎为主，最常见的全身性疾病均为高血压，其次为糖尿病。透析时间和透析后结核检出时间均以大于1年为常见(表1)。
2.2 临床表现
在出现的首发症状中，PTB组咳嗽咳痰及发热比例明显高于EPTB组，而病变部位疼痛比例则明显低于EPTB组(P<0.05)。两组其余症状相似，包括胸闷、乏力、纳差、腹胀等(表2)。46例EPTB患者中，常见的结核感染部位为骨和关节(16例，34.8%)、胸膜(14例，30.4%)、腹膜(5例，10.9%)，其中25例(54.3%)存在两个及以上部位的感染。
2.3 实验室及影像学检查
PTB组痰结核分枝杆菌培养的阳性率为29.5%，而EPTB组患者的感染部位虽以肺外为主，但仍发现3例(9.1%)痰培养为阳性。两组γ干扰素释放试验阳性率差异无统计学意义。PTB组及EPTB组结核病的确诊方式均以CT或MRI影像学检查为主，此外，痰涂片或结核分枝杆菌培养是PTB的次常见诊断方式，穿刺活检是EPTB的次常见诊断方式，两组比较差异有统计学意义(P=0.005，表3)。
PTB组与EPTB组的血清学检查结果相似，均表现为淋巴细胞、血红蛋白、白蛋白降低比例较高，红细胞沉降率、CRP升高比例较高，部分患者表现为ADA升高，但两组间差异无统计学意义(表4)。
2.4 治疗及转归
133例患者均在继续行MHD的情况下给予抗结核药物治疗，方案主要选择异烟肼或帕司烟肼+利福平或利福喷丁，个体化联合乙胺丁醇和(或)吡嗪酰胺及左氧氟沙星等抗感染治疗，其中1例EPTB患者在抗结核药物治疗的基础上行腰椎结核病灶清除+植骨融合内固定术，两组治疗好转率接近。PTB患者4例加重，2例死亡(死因分别为脑出血、急性心肌梗死)；EPTB患者3例死亡(死因分别为高钾血症、硬膜下出血及呼吸衰竭)；在抗结核治疗过程中，22例患者出现药物不良反应，不良反应发生率两组间差异无统计学意义(表5)。PTB组与EPTB组双下肢麻木、视物模糊等不良反应发生率差异无统计学意义(P>0.05，表6)。
3 讨论
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本研究主要比较了行MHD的ESRD并发PTB或EPTB患者的人口学指标、临床特征、诊断方式及预后方面的差异。结果表明，两组虽均以男性为主，但EPTB组女性比例较PTB明显增高；由于结核感染的部位不同，患者表现出了不同的首发症状，PTB患者以发热及咳嗽咳痰为常见首发症状，EPTB患者则以病变部位疼痛为主要首发症状；PTB及EPTB的确诊方式均以CT或MRI为主，次常见诊断方式PTB为痰涂片或培养，EPTB为穿刺活检。两组γ干扰素释放试验阳性率无明显差异；实验室检查结果显示，两组淋巴细胞、血红蛋白、白蛋白降低及红细胞沉降率、CRP升高的比例均较高；两组抗结核治疗的疗效及不良反应均无明显差异，主要不良反应有双下肢麻木、视物模糊及消化道反应等。
有研究发现，1992—2017年中国的结核发病率为54.18/10万~147.65/10万[13]，而本研究中行MHD的ESRD合并结核患者占总透析人数的比例(3.3%)远高于普通人群，考虑原因除这类人群本身结核发病率较高之外，还可能与我院有结核病区、部分患者系从他院转诊而来有关。本研究纳入的ESRD患者多为中老年人，通常合并糖尿病、高血压等全身性疾病，长期应用免疫抑制剂或MHD治疗后，易造成机体免疫力低下，因此，潜伏于肺部的结核菌可经淋巴或血行播散到其他器官，引起EPTB。全球普通人群中，EPTB占结核病的比例为13.4%~36.9%[14-15]，而在接受血液透析的患者中，EPTB发生率为38.0%~80.0%[16-17]。在我国，2008—2017年普通人群中EPTB占结核病的比例从29.8%增至31.4%[10]。本研究人群中EPTB占29.5%，与我国普通人群比例相当，但低于全球MHD治疗患者，说明我国MHD患者的EPTB有其自身特征。
美国、德国、尼泊尔等国家的多项研究证实，EPTB在年轻患者中较为常见，且女性发生EPTB的风险高于男性[7-10]。而在本研究中，PTB与EPTB患者均主要为中老年人，且两组年龄无明显差异，可能是研究人群的特殊性所致。本研究还发现PTB组与EPTB组的性别分布存在明显差异，两组均以男性为主，但EPTB组的女性比例高于PTB组，与多数研究一致。女性更易患EPTB的原因仍不清楚，有研究认为可能与社会经济文化因素(贫困、营养状况、生育情况等)[18]、吸烟习惯[9]或内分泌因素[7]有关。
大多数研究表明，淋巴结是EPTB最常见的感染组织[4,8-9]。印度一项针对透析时发生结核患者的研究认为，胸膜和腹膜是EPTB的常见部位[17]。本研究发现，EPTB最常见的感染部位为骨和关节，与在我国普通人群中的研究结果一致[10]。另一项针对我国EPTB患者的回顾性研究发现，约70%的EPTB患者合并多个部位的结核感染[19]，而本研究中该比例为54.3%，低于普通人群。这些差异表明EPTB的感染部位可能与社会或地理环境因素有关，是否与MHD有关仍有待研究。
有研究发现，咳嗽、咳痰与PTB密切相关[20]，而感染部位疼痛(48.1%)则为EPTB最常见的症状[21]。本研究发现，PTB的首发症状为咳嗽、咳痰(59.8%)及发热(60.9%)，而EPTB则以不同感染部位疼痛为首发症状(41.3%)，与之前的研究结果一致。由于EPTB患者还伴有发热、胸闷、乏力、纳差等一些全身症状，通过临床症状来诊断EPTB较为困难，还应结合实验室、影像学检查及组织活检结果进行综合评判。
痰结核分枝杆菌培养是诊断结核的金标准。本研究中，PTB组痰培养阳性率为29.5%，表明该检查的阳性率较低，须结合其他方法进行确诊。此外，在EPTB患者中，感染部位虽以肺外为主，仍发现3例(9.1%)痰培养阳性，表明在此类患者中仍需重视痰培养检查。γ干扰素释放试验可作为判断机体是否存在结核菌感染的检测方法[22]，但无法对结核感染部位进行定位，因此诊断PTB及EPTB还应结合影像学检查及病理活检等方法。本研究中，CT/MRI检查结果显示PTB病变主要表现在肺部，EPTB病变主要表现在骨、关节、胸膜、腹膜、淋巴、脑、肾等部位。对于EPTB，常常需要进行病理穿刺活检以明确诊断。由于EPTB可发生在多个系统及脏器，可表现出各种临床症状，容易出现误诊、漏诊，因此在诊断过程中应详细询问病史并进行体格检查，充分利用超声、CT、MRI、穿刺活检等多种检查手段[23]。
结核患者通常会出现贫血、红细胞沉降率及CRP升高[21]，本研究中PTB及EPTB患者同样具有此类表现。研究表明，T淋巴细胞介导的免疫反应在控制结核感染中起重要作用[24]，在疾病活动期分泌多种细胞因子，如白细胞介素-2(IL-2)、肿瘤坏死因子-α(TNF-α)及γ干扰素(IFN-γ)，提供免疫保护作用[25]。营养不良和血清蛋白水平降低可导致淋巴细胞总数减少，辅助性(CD4+)T细胞与抑制性(CD8+)T细胞比值降低，由淋巴细胞产生的细胞因子相应减少，进一步影响机体的免疫力及结核病患者的预后[26]。本研究人群由于受ESRD、高血压、糖尿病等慢性疾病，高龄及长期血液透析的影响，常会出现营养不良，使血清白蛋白、血红蛋白等降低，有利于结核病的发展。因此，在抗结核治疗的同时，应提高对患者营养状况的关注，及时进行积极干预。CRP、ADA为肝损伤、炎症反应及肿瘤的主要标志物[27]。患者感染结核后，T淋巴细胞被激活，发生炎症反应，可使红细胞沉降率加快，CRP、ADA升高。本研究结果显示，PTB及EPTB患者的红细胞沉降率、CRP水平明显升高，可考虑作为诊断结核病的参考依据。多项研究发现，ADA在结核性胸膜炎时明显升高[28-29]，其中一项研究中的PTB、EPTB患者ADA水平升高比例分别达91.5%、84.9%[27]。而本研究中PTB组及EPTB组患者ADA升高的比例分别为42.0%及30.8%，因此，ADA的实际应用价值尚待进一步观察。
在结核病的治疗过程中，应遵循“早期、联合、适量、规律、全程”的原则。本研究中首选的一线药物为异烟肼、利福平、乙胺丁醇、吡嗪酰胺、左氧氟沙星。由于透析人群的尿毒症毒素作用，通常认为抗结核药物不良反应在透析患者中较普通人群发生率高且病情较重，发生在神经系统的不良反应也较多，如双下肢麻木等，但多数患者预后良好。长期行MHD的患者基础疾病较复杂，可针对患者的具体反应采取个体化治疗方案[30]。本研究在治疗转归及不良反应方面，未发现PTB组与EPTB组存在明显差异，表明经抗结核和个体化治疗，PTB与EPTB均可取得较好的疗效。
本研究为单中心、回顾性研究，病例数有限，且存在部分项目检测率不高、遗漏或者无法采集到等问题，存在一定的局限性。但是，由于本院有结核病区，样本量在国内外类似研究中已属于较大者。今后应争取开展多中心、前瞻性研究，以进一步明确行MHD的ESRD并发PTB及EPTB患者的临床特点。
综上所述，本研究发现，行MHD的ESRD患者中PTB及EPTB均以男性为主，但EPTB的女性比例增加；PTB的首发症状以发热和咳嗽为主，EPTB则以病变部位疼痛为主；两组确诊方法均以影像学检查为主，痰涂片或培养(PTB)、穿刺活检(EPTB)是次常见诊断方式。由于EPTB感染部位多变，容易漏诊或误诊，应对高危人群予以关注，尤其是女性人群。行MHD的ESRD患者由于免疫力降低，极易感染结核分枝杆菌，因此应定期筛查，并充分结合不同的检查方法，争取早期诊断、早期治疗，降低发病率及病死率。PTB与EPTB均应坚持抗结核治疗，同时及时关注患者的营养状况，采用个体化治疗方案，从而改善患者预后，提高患者生活质量。
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2021年第46卷第3期
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doi: 10.11855/j.issn.0577-7402.2021.03.10
  • 接收时间：2020-12-26
  • 首发时间：2025-12-26
  • 出版时间：2021-03-28
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  • 收稿日期：2020-12-26
  • 修回日期：2021-02-21
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    1河北北方学院研究生院，河北 张家口 075000
    2解放军总医院第八医学中心肾内科，北京 100091

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2种不同金属材料的力学参数
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Family		 属数
Number of
genus		 种数
Number of
species		 占总种数比例
Percentage of
total species (%)		 属
Genus		 种数
Number of
species		 占总种数比例
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鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
栓菌属 Trametes 5 2.39
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