Frequency of uremic and tuberculous pleuritis having exudative lymphocytic pleural effusion in patients with advanced renal disease

Syed Naveed Tahir , Mehwish Shaheen , Talha Mahmood, Nauman Rafi Rajput, Muhammad Saqib, Muhammad Ahmed, Hira Ishtiaq. Frequency of Uremic And Tuberculous Pleuritis Having Exudative Lymphocytic Pleural Effusion in Patients with Advanced Renal Disease. Cardiometry; Issue No. 29; November 2023; p. 122-126; DOI: 10.18137/cardiometry.2023.29.122126; Available from:

Tuberculous pleural effusion is a diagnostic and therapeutic problem due to the limitations of availability traditional diagnostic tools. To resolve this problem there have been many clinical research works carried out during the past decade (Vásquez-Rodri- guez et al., 2019). Pleural fluid analysis showed that patients with tuberculous pleurisy had a significantly lower pleural to serum lactic dehydrogenase ratio, total pleural leukocytes, and polymorph nuclear count compared to patients with parapneumonic effusion (Yoon et al., 2019).

Rationale of this study is to determine the frequency of uremic and tuberculous pleuritis in patients with advanced renal disease. Through literature, not much work has been found in literature regarding the issue. Moreover, local data is also scarce which could help us to determine the extent of uremic and tuberculous pleuritis in patients with advanced renal disease. Uremic and tuberculous pleural effusion share similar biochemical abnormalities like exudative and lymphocytic predominance. It is important to differentiate the two entities as the treatment is entirely different. This study will help us to attain the local magnitudes of complication of hemodialysis in patients with advanced renal disease. So that we may be able to implement results in local setting and implement the regular screening of renal failure patients for uremic and tuberculous pleuritis to prevent complications and cost burden of treatment of such conditions in dialysis patients (Vikrant, 2019).

Aims & Objectives: To determine the frequency of uremic and tuberculous pleuritis in patients with advanced renal disease.

Place and duration of study : It was a Cross-sectional study and it was conducted at department of Pulmonology Shaikh Zayed Medical Complex, Lahore from 2nd December, 2020 till 1st June, 2021.

Methodology: 150 patients who fulfilled the inclusion criteria were enrolled Informed consent was taken from each patient. Demographic information (name, age, sex, BMI and duration of renal disease) was noted. Then diagnostic pleural tap was done and exudate sample was taken. All exudative samples were further assessed by pleural biopsy and sample was sent to the laboratory of the hospital for histological assessment of uremic or tuberculous pleuritis. The collected data was analyzed statistically by using SPSS version 20. Quantitative variables like age, BMI and duration of renal disease will be calculated as mean and standard deviation. Qualitative variables like gender, uremic and tuberculous pleuritis was calculated as frequency and percentage. Data was stratified for age, gender, BMI and duration of renal disease. Post-stratification, chi-square test was applied to compare uremic and tuberculous pleuritis in stratified groups keeping p-val-ue≤0.05 as significant.

Results

One hundred fifty patients were enrolled, 83 (55.3%) male and 67 (44.7%) female. The mean ageof the patients was 39.5±14.2 years, 28.7% patients had age between 16 to 30 years, and 38% had aged between 31 to 45 years while 33.3% of study participants had age more than 46 years. Seventy percent of study participants had normal BMI, one patient was overweight and 29.3% were in obese category. The duration of renal disease was 35.8±14.6months. Uremic pleuritis was present in 69.4% and tuberculous pleu-ritis was seen in 30.6% patients. Data was stratified for age, gender, BMI and duration of disease (table 1). Post-stratification chi square test was applied and it was seen that age, gender and duration of disease was significantly associated with uremic and tuberculous pleuritis as indicated by a p value of 0.026, 0.048 and 0.007 respectively.

Discussion

The current study revealed that uremic pleuritis was more common compared to tuberculous pleuritis in patients with advanced renal disease i.e. 69.4% vs 30.6% respectively. These findings were significantly associated with age, gender and duration of disease as indicated by a p value of < 0.05. With respect to duration of renal disease, uremic pleuritis was more commonly seen in short duration and extremely long duration illness i.e. in 24.7% patients and tuberculous pleuritis was more frequently seen in patients whose disease was of short duration i.e. in 19.3% and the association was statistically significant (p=0.007). In terms of gender, uremic pleuritis was equally present in both males and females i.e. 34.5%, whereas, tuber-

Age group	Pleuritis		Total	P-value
	Uremic	Tuberculous
Young Age (16-30 years)	35 (23.4%)	8 (5.3%)	43 (28.7%)	0.026
Early Middle Age (31-45 years)	41 (27.3%)	16 (10.7%)	57 (38%)
Late Middle Age (46-65 years)	28 (18.7%)	22 (14.6%)	50 (33.3%)
Total	104 (69.4%)	46 (30.6%)	150 (100%)
Gender	Pleuritis		Total	P-value
	Uremic	Tuberculous
Male	52(34.7%)	31(20.6%)	83(55.3%)	0.048
Female	52(34.7%)	15(10%)	67(44.7%)
Total	104(69.3%)	46(30.6%)	150(100%)
BMI	Pleuritis		Total	P-value
	Uremic	Tuberculous
Normal BMI (20 to 25 Kg/m2)	75 (50%)	30 (20%)	105 (70%)	0.514
Overweight (25.1 to 30 kg/m2)	1 (0.7%)	0 (0%)	1 (0.7%)
Obese (>30 kg/m2)	28 (18.7%)	16 (10.6%)	44 (29.3%)
Total	104 (69.4%)	46 (30.6%)	150 (100%)
Duration of Renal Disease	Pleuritis		Total	P-value
	Uremic	Tuberculous
Short Duration (12-24 months)	37 (24.7%)	29 (19.3%)	66 (44%)	0.007
Long Duration (>24-48 months)	30 (20%)	8 (5.3%)	38 (25.3%)
Extremely Long Duration (>48 months)	37 (24.7%)	9 (6%)	46 (30.7%)
Total	104 (69.4%)	46 (30.6%)	150 (100%)

culous pleuritis was more frequently seen in males, i.e. in 20.6% and this association was found to be significant statistically (p=0.026). With respect to age, uremic pleuritis was more frequent in early middle age individuals who had advanced stage renal disease i.e. in 27.3% and tuberculous pleuritis was more frequently encountered in late middle age individuals i.e. in 14.6%, and this association was also statistically significant (p=0.048). Pleuropulmonary problems are frequently encountered in patients with advanced renal disease and there are several reasons for it (Jabbar,

In a study by Ibrahim, MT. et al in 2010, and the commonest cause of pleural effusion was tuberculosis i.e. in 58.2% and only 6% showed uremic pleuritis. The study included both transudative as well as exudative pleural effusion. In another study by Kumar AP. et al in 2015, included both transudative and exudative cases and revealed that tuberculous pleuritis was seen in 28% and uremic pleuritis was seen in 14% in patients with chronic renal disease. The current study only included patients with exudative lymphocytic pleural effusion and thus found different results i.e. uremic pleuritis was more 79 common (69.4%) compared to tuberculous pleuritis (30.6%). This difference in frequency of causative factor between the two studies is mainly because of the population being studied. Our study was limited to patients with advanced renal disease who only had exudative lymphocytic effusion. Doelken P et al in 2013 evaluated patients who were on long term dialysis for the presence of pleural effusion and factors leading to it. The authors revealed that 25% had pleural effusion and the commonest causes were heart failure (64.3%), hypervolemia (33.3%), tuberculosis (7.9%) and uremia (6.3%). Current study only considered two etiological factors for causation of pleural effusion in patients with advanced renal disease and found that uremic pleuritis was more common compared to tuberculous pleuritis. The study had certain limitations. Firstly, it was carried out at a single center and the sample size was small, so the results cannot be generalized. Secondly, other causes and types of pleu-ritis were not evaluated in the study.

Conclusion

The current study concluded that uremic pleu-ritis was more frequently found as compared to tuberculous pleuritis in patients with advanced renal disease. Pleural effusion that was present in patients on maintenance dialysis was mainly due to uremia. Pleuritis was significantly associated with age, gender and duration of renal disease. Future studies must be carried out on a large sample size and must look in to the different effective strategies that can reduce the frequency of this complication that is associated with advanced renal disease, thus helping in reducing further morbidity associated with the condition.

CONTRIBUTIONS

Syed Naveed Tahir – wrote the main manuscript text, conception, design of the study, acquisition of data, manuscript review and revision, data and models’ analysis. Dr. Talha Mahmud ,Dr Muhammad Saqiba, Mehwish Shaheen, and Nauman Rafi Rajput – conception and design of the study, manuscript review Hira Ishtiaq and revision, Dr Muhammad Ahmed – acquisition of data, manuscript review and revision.

ETHICS APPROVAL

Approval was obtained from the ethics committee Sheikh Zaid Hospital, Lahore, Pakistan. The procedures used in this study adhere to the tenets of the Declaration of Lahore, Pakistan.

CONFLICT OF INTEREST

The authors have no competing interests to declare that are relevant to the content of this article.

FUNDING

No funding was acquired.