人工透析と結核症-2-人工透析時のツベルクリン反応の動態に関する臨床的研究

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As previously reported, high incidence of miliary tuberculosis was noted among patients with chronic renal failure treated with regular haemodialysis. It is well known that among patients who had been administered steroid or immunosuppressive agents and whose cellar immunity diminished, risk of miliary tuberculosis was significantly higher. No report has been available in the literature on the results of serial tuberculin testing among patients who were treated with regular haemodia lysis. We studied the changes of tuberculin reaction in 36 patients with chronic renal failure between 23 to 61 years of age. None of these patients received any kind of steroid or immunosuppresive therapy during haemodialysis treatment. Eight of these patients were examined by serial intracuta neous tuberculin tuberculin tests with intermediate strength PPD. When it did not react or was interpreted as negative reaction, a re-test by second strength PPD was carried out. A positive reaction was defined as an area of erythema with a diameter 10mm and larger developing 48 hours after the antigen injection. The frequency of positive skin tests to PPD is high in Japan because of a high prevalence of tuberculosis infection in the higher age groups and extensive BCG vaccination in the younger age groups. The distribution of the tuberculin sensitivity in patients under various frequency of haemodia lysis treatment is indicated in Table 1. Among 32 patients under regular haemodialysis less than 100 times in total, there were 18 positive reactors (56.2%), 5 weakly positive reactors (15.7%) and 9 negative reactors (28.1%), while among 24 patients more than 101 times in total, 12 showed positive reactions (50%) and 12 showed negative reactions (50%). No positive reactions were observed among all four patients more than 300 times in total Serial tuberculin skin tests were performed in eight patients. As shown in Fig. 1, their skin test reactivity decreased with the frequency of haemodialysis treatment. Two patients among them converted to negative after receiving haemodialysis for more than 90 times and another two after more than 300 times. Two patients were negative to PPD skin test from the beginning of haemo dialysis therapy and died, and another two are still positive at present. The cause of the negative conversion of skin reactivity in these patients does not rel ate to the severity of uremia because they have been well treated with haemodialysis therapy. These findings suggest that the mechanisms other than uremia itself related to negative conversion of t uberculin skin test. It might be possible that the substances cause negative conversion of tuberculin skin test, such as ‘transfer factor’ which Lawrence had reported at first, would be lost during haemodia lysis treatment. Whether tuberculin reaction convert to negative or not, when leukopenia persists for a long time in these patients, is not known as yet. Considering these results, the factors relating to manifestation of miliary tuberculosis reported previously might due to diminished cellular immunity which was shown by tuberculin negative conversion among haemodialised patients. We have to aware the increased susceptibility to miliary tuberculosis among patients under regular haemodialysis and a special caution must be paid for the early diagnosis of the disease.

著者

藤野忠彦
慶応義塾大学医学部五味内科

人工透析と結核症-2-人工透析時のツベルクリン反応の動態に関する臨床的研究

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