How should we treat tuberculosis in adult patients with chronic kidney disease? Key messages from the British Thoracic Society Guidelines

This review highlights the key messages from the 2010 British Thoracic Society Guidelines on the management of Mycobacterium tuberculosis infection and disease in adult patients with chronic kidney disease. These guidelines were developed in response to many requests for advice from respiratory and infectious diseases physicians who treat patients with tuberculosis, as there was very little information available to help clinicians manage the disease in this population of often very sick patients. Renal units in the United Kingdom were prescribing variable chemoprophylaxis regimens that frequently had no basis in evidence, and drug doses used to treat tuberculosis were often inappropriate because of clinicians’ natural concern about poisoning a patient with little or no renal function. The guidelines address these issues together with when and how to screen for latent infection and the different needs of patients with renal impairment, those needing dialysis and those with a transplanted kidney. It became very clear in compiling these guidelines that there is a shortage of both background information on rates of tuberculosis in such patients in countries with low background prevalence, and good randomized controlled trials of treatment regimens. Wherever possible, the recommendations made are evidence-based, but this was not always available. This review gives a summary of those recommendations and reiterates some of the important messages; in particular, tuberculosis should be managed with the full involvement of the chest or infectious diseases physician who is the local lead for this important infection.