结核γ干扰素释放试验酶联免疫试管法和结核菌素皮试试验对行维持性血液透析合并结核患者的诊断和预后判断价值研究

目的　探讨结核γ干扰素释放试验酶联免疫试管法（QFT）和结核菌素皮试试验（TST）对结核高流行地区（海南地区）行维持性血液透析（MHD）合并结核〔包括隐性结核（LTBI）和结核病〕患者的诊断、预后判断价值。方法　选择2013—2015年在海南省人民医院血液净化中心行MHD时间>3个月的患者198例，收集患者的一般资料，进行QFT和TST，评估其对MHD合并结核的诊断和预后判断价值。采用多因素Logistic回归分析分析QFT阳性和TST阳性的影响因素。观察患者3年的预后情况，绘制生存曲线，采用Cox比例风险模型分析其预后影响因素。结果　最终156例患者完成研究，其中男109例、女47例，平均年龄（54.4±16.6）岁，平均透析龄（1.9±0.4）年。MHD患者QFT阳性率为34.6%（54/156），TST阳性率为67.9%（106/156），TST与QFT结果无一致性（Kappa值=0.053，P=0.405）。多因素Logistic回归分析显示，在校正其他因素的情况下，性别〔OR=0.345，95%CI（0.144，0.828），P=0.017〕、有无卡介苗接种瘢痕〔OR=0.345，95%CI（0.144，0.828），P=0.017〕是QFT阳性的影响因素；性别〔OR=2.836，95%CI（1.120，7.177），P=0.028〕、淋巴细胞分数〔OR=3.573，95%CI（1.410，12.295），P=0.043〕是TST阳性的影响因素。37例LTBI患者中11例转为肺结核（29.7%）。本组患者3年结核患病率为42 948.7/10万。MHD患者1、2、3年生存率分别为89.7%、77.6%、69.9%，粗死亡率（CDR）为301.3/1 000人。Cox比例风险模型分析发现QFT阳性、C反应蛋白升高是生存的不利因素；抗结核治疗、前清蛋白升高是生存的有利因素（P<0.05）。结论　在海南地区，男性MHD患者QFT阳性率较高；TST与QFT对MHD合并结核的诊断无一致性。QFT阳性、C反应蛋白升高是生存的不利因素，抗结核治疗、前清蛋白升高是生存的有利因素。在结核高流行地区MHD患者合并LTBI、结核病的诊断依然需要结合流行病学、病史、结核易感因素、肺部影像学，排除其他感染，行试验性抗结核治疗，需大力推进组织病理、肺支气管肺泡灌洗液的诊断措施。

Diagnostic and Prognostic Values of Quantification ELISA Interferon-γ Release Test Assays and Tuberculosis Skin Test for Tuberculosis Patients Undergoing Maintenance Hemodialysis

Objective　To study the diagnostic and prognostic values of quantification ELISA interferon-γ release test（QFT） and tuberculosis skin test（TST） for patients with tuberculosis〔including both latent tuberculosis infection（LTBI） and tuberculosis（TB）〕 undergoing maintenance hemodialysis（MHD） in areas with high prevalence of tuberculosis.Methods　Totaled 198 patients who underwent MHD in Blood Purification Center，Hainan General Hospital，for more than 3 months during 2013—2015 were enrolled.All of them were given a 3-year follow-up.Baseline clinical data were collected.The results of QFT and TST were also obtained and their values in the diagnosis and prediction of the prognosis of these patients were evaluated.Multivariate Logistic regression analysis was performed to investigate the influencing factors for positive results of QFT and TST.The prognosis of patients in 3 years was observed，and survival curves were drawn.Cox proportional hazards regression analysis was carried out to explore the factors associated with the prognosis.Results　156 cases who completed the study were included in the final analysis，including 109 males and 47 females，with an average age of（54.4±16.6）years and an average hemodialysis duration of（1.9±0.4） years.The prevalences of positive QFT，positive TST were 34.6%（54/156），67.9%（106/156），respectively.The results of TST and QFT in identifying TB showed no consistency（Kappa=0.053，P=0.405）.Multivariate Logistic regression analysis revealed that，after adjusting for other factors，sex〔OR=0.345，95%CI（0.144，0.828），P=0.017〕and no BCG vaccine scar〔OR=0.345，95%CI（0.144，0.828），P=0.017〕were risk factors for having a positive QFT result，the sex 〔OR=2.836，95%CI（1.120，7.177），P=0.028〕and the total lymphocyte count〔OR=3.573，95%CI（1.410，12.295），P=0.043〕were risk factors for having a positive TST result.Of the 37 patients identified with LTBI，11（29.7%） developed TB.The 3-year prevalence of TB in these patients was 42 948.7/100 000.The 1-，2-，3- year survival rates were 89.7%，77.6%，and 69.9%，respectively.Crud death rate was（CDR）301.3/1 000.Multivariate Cox proportional hazard regression analysis found that positive QFT results and elevated C-reactive protein（CRP） were unfavorable prognostic factors for the overall survival，while anti-TB treatment and elevated prealbumin were favorable prognostic factors for the overall survival（P<0.05）.Conclusion　In areas with high prevalence of tuberculosis in Hainan Province，among the CKD patients undergoing MHD，males were more likely to have a positive QFT result.The results of TST and QFT in diagnosing TB demonstrated no consistency.Positive QFT results and elevated CRP were unfavorable factors whereas anti-TB treatment and elevated prealbumin were favorable prognostic factors for the overall survival.In this population，the diagnosis of LTBI or TB should be based on epidemiologic data，past medical history，predisposing factors of TB，lung imaging data，exclusion of other infections and results of experimental anti-TB treatment.In addition，diagnostic measures such as histopathological examination and determination of bronchoalveolar lavage fluid concentration should be promoted vigorously.