RESUMO
Background: Tuberculosis (TB) can have manifestations closely mimicking autoimmune diseases. The prevalence of autoantibodies in TB varies among different populations. Objectives: To study the prevalence of anti-neutrophilic cytoplasmic antibodies (ANCA) and antinuclear antibodies (ANA) in pulmonary tuberculosis (PTB). Methods: This was a cross-sectional, observational study. Subjects with microbiologically confirmed PTB, either via smear or culture positivity on sputum or bronchoalveolar lavage (BAL) fluid, or positive rapid diagnostic tests were included. ANCA against proteinase-3 (PR3), myeloperoxidase (MPO), lactoferrin, and elastase were tested using an enzyme-linked immunosorbent assay (ELISA). ANA was detected using indirect immunofluorescence (IIF). Results: Eighty-nine subjects with a median [interquartile range (IQR)] age of 28 (20–46) years, 67.4% males, were recruited. Eighty-one subjects had microbiological confirmation on sputum examination, and eight required examination of BAL fluid. Sera were drawn from 62 treatment-naïve subjects, the rest (27) were on antitubercular therapy (ATT). Eighty-six (96.6%) subjects tested positive for anti-elastase antibody, seven of which were also positive for anti-PR3. None were positive for anti-MPO and anti-lactoferrin. Six (6.7%) subjects tested positive for ANA. None of the subjects had features of underlying connective tissue disease or vasculitis. Conclusion: PTB patients showed a high prevalence of anti-elastase and a low prevalence of ANA and anti-PR3 antibodies. ANCA positivity should be interpreted with caution in TB endemic areas. The role of anti-elastase antibodies in differentiating TB from ANCA-associated vasculitis (AAV) needs further research.
RESUMO
Background. Late referral of patients with chronic kidney disease (CKD) to a nephrologist has been shown to be associated with greater morbidity and adverse clinical outcomes. Methods. We did a prospective cross-sectional study of 2490 consecutive, newly diagnosed patients with end-stage renal disease (ESRD) referred to the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh over 2 years. The referral pattern was classified on the basis of the interval between first visit to a nephrologist and initiation of renal replacement therapy (RRT). If the patient reported later to a nephrologist, the disease would have progressed more, and the time interval to initiation of RRT would thus be shorter. A time interval of <3 months was classified as late referral (LR), 3–12 months as intermediate referral (IR) and >12 months as early referral (ER). The demographic and clinical characteristics and co-morbid conditions were compared, and factors associated with LR and outcomes were evaluated. Results. About 75% of patients were referred late. Poor socioeconomic status, low level of education and reduced access to reimbursement of treatment costs contributed to LR. The aetiology of ESRD could not be established in a larger number of LR patients as compared to the other groups. LR patients had a higher prevalence of uraemic complications and required emergency dialysis more frequently. A higher proportion of LR patients were lost to follow up because they could not afford to continue dialysis. Early mortality was higher in the ER group than in the other groups. ER patients were older, more likely to have diabetic nephropathy and a higher burden of co-morbid conditions. They were also more likely to choose continuous ambulatory peritoneal dialysis or undergo transplantation. Only 28% of all patients continued RRT beyond 3 months. Conclusion. A large majority of patients with ESRD in India seek medical attention late, usually in advanced stages of CKD with uraemic complications. LR is more frequent in younger patients and those with non-diabetic kidney disease, and is associated with poor socioeconomic status, lack of education and poor outcomes.