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| BRIEF COMMUNICATION |
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| Does tuberculin skin test predict tuberculosis in patients with end-stage liver disease? |
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| Mohamed S. Al-Moamary, Salah Al-Baz, Adel Alothman, Ziad Memish, Hamdan Al-Jahdali, Abdulmajeed Al-Abdulkareem
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| Saudi Medical Journal 2003; Vol. 24 (11): 1269-1270 |
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The incidence of tuberculosis (TB) after solid organ transplantation has been reported to be between 1-4%. As a screening test for TB, tuberculin skin test (TST) has been utilized in cases evaluated for liver transplantation (LT). A recent study reported that 16.8% of LT candidates in the period from 1988-1998 had positive TST, and TB was reported in 1% of cases who underwent an LT. Tuberculosis is known to complicate LT, as LT has unheralded risk factors for the development of TB as of possible reactivation of latent infection or primary TB in immunosuppressed host. Despite the increasing risk of active TB in transplanted patients, there is no consensus regarding the appropriate treatment of asymptomatic TB infection in this category. The Kingdom of Saudi Arabia (KSA) is a country with an intermediate prevalence of TB. In a nationwide community survey of TB epidemiology in KSA, the prevalence of a positive TST among the Saudi population was 30%. In this setting, the action based on a TST in end-stage liver disease (ESLD) is somewhat controversial.1,2 The objective of this paper is to study the prevalence and value of a positive TST on patients assessed for LT and the prevalence and value of a TST in cases with ESLD evaluated for LT.
We did a retrospective chart review of patients with ESLD referred for LT evaluation at the King Fahad National Guard Hospital, Riyadh, KSA. All patients evaluated in the period between 1994-1997 were studied. The inclusion criteria are 1. Patients with ESLD referred for LT, 2. Tuberculin skin test carried out at the time of evaluation, and 3. Follow-up period for at least 12 months or TB disease development within 12 months. Numbers were expressed as mean ± standard deviation. Whenever there was data in 2x2 table, Chi Square was used as appropriate.
The liver transplantation program evaluated 260 patients with ESLD in the period from 1994-1997. Tuberculin skin test results were available for 160 patients (61.5 %). Forty-two patients had positive TST with a prevalence of 26.3%, while the prevalence of a positive TST in a nationwide wide survey among Saudi patients was 30% (p=0.21).4,5 One hundred and nineteen patients (74.4%) met the inclusion criteria. Of those 119 eligible patients, 31 had positive TST (26.1%). The mean age was 46.6 years (±16.9) with a male to female ratio of 1.4:1. The etiology of liver cirrhosis was as follow: Hepatitis C virus in 77 patients (64.7%), Hepatitis B virus in 5 patients (4.2%), and others etiologies for the remaining 24 patients (21.1%). The follow-up period was 26.4 months (± 18.4). The outcome of eligible patients at the time of data analysis was as follows: 45 (37.8%) were transplanted, 50 (42%) had not yet have the transplantation, and 24 (20.2%) died while on the waiting list. Among the 45 patients who underwent LT, 15 (33.3%) had a positive TST. Of the 75 patients who did not undergo an LT, 16 (21.3%) had a positive TST (p=0.065). Of the 31 patients with a positive TST, 2 (6.5%) developed tuberculosis, while the other 2 (2.3%) with negative TST developed tuberculosis. Four patients (3.4%) developed tuberculosis, one patient was transplanted, and 3 were not. Only 3 patients (9.7%) with a positive TST had isoniazid prophylaxis and one developed drug-related hepatitis.
We conclude that TB is preventable when there is a high degree of suspicion in endemic areas. Most of the cases could be diagnosed promptly with appropriate investigation. Though a TST in our study did not predict the development of TB in ESLD, it should raise suspicion for the development of TB in the future and warrant the use of TB prophylaxis after transplantation in LT candidates.
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