신기능에 따른 폐외결핵의 임상적 특징과 예후
Comparative analysis of the clinical features and prognosis of extrapulmonary tuberculosis according to the renal function
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목적: 만성 신질환 환자에서 세포성 면역기능이 감소되어 결핵에 이환될 위험성이 높으며, 특히 폐외결핵의 발생 빈도가 높은 것으로 알려져 있다. 이에 신기능에 따른 폐외결핵의 임상양상, 치료 반응, 질환과 연관된 사망률의 차이점을 비교하였다. 방법: 2003년 1월부터 2007년 12월까지 폐외결핵으로 진단된 18세 이상의 환자를 대상으로 하였고, 진단 당시의 크레아티닌 값을 이용하여 MDRD 공식으로 계산한 추정 사구체 여과율(eGFR)이 60 mL/min/1.73 m2을 기준으로 신기능 장애군(Group I)과 정상 신기능군(Group II)으로 분류하여 폐외결핵의 임상상, 치료성공률, 사망률 및 치료기간의 차이를 후향적 비교 분석하였다. 결과: 총 342명의 환자 중 Group I은 30명으로 이중 투석을 시행하고 있는 환자는 6명이었고, Group II는 312명으로, 각각의 평균 사구체 여과율은 34±19 mL/min/1.73 m2, 102±26 mL/min/1.73 m2이었다. Group I에서 고연령, 빈혈, 저알부민증이 많았으며, 고혈압, 당뇨병 및 심혈관계 질환을 동반한 경우가 많았다. 폐외결핵의 발생 부위는 두 환자군 모두 (Group I vs. Group II)에서 흉막(30.0% vs. 28.2%)이 가장 빈도가 높았고, 신경계통(23.3% vs. 16.3%)과 림프절(16.7% vs. 17.6%)의 감염이 흔하였으나, 통계학적 유의성은 없었다 (p=0.379). 모든 환자들은 표준 결핵화학요법인 HERZ, HER 및 HRZ 등을 용량 조절하여 치료하였으며, 두 환자군 모두에서 치료 실패 및 재발은 없었다. 결핵과 연관된 사망률은 Group I에서 높았으며(Group I, 22.2% vs. Group II, 2.8%, p<0.001), 연령, 혈색소 및 알부민, 당뇨병, 고혈압 및 심혈관계 질환의 유무를 보정하였을 경우에도 Group I이 사망의 위험률이 높았다(HR=11.51, 95%CI 2.512~52.741; p=0.002). 치료 중 이탈된 환자 및 사망환자를 제외하였을 경우, Group I이 치료 기간이 짧았다(278±110일 vs. 367±170일, p=0.009). 결론: 신기능 장애 환자에서 폐외결핵에 대한 치료기간이 연장되지 않았고 사망을 제외한 치료실패와 재발이 없었으나 폐외결핵으로 인한 사망률은 높았고, 신기능 저하 자체가 사망의 독립적인 위험 요소였다. 그러므로 신기능 장애 환자에서 폐외결핵에 대한 적극적인 진단 및 치료가 더 요구된다고 판단한다.
Abstract
Background/Aims: There is an increased risk of tuberculosis (TB) with impaired cellular immunity and extrapulmonary TB is more common in patients with chronic kidney disease. We explored the clinical features and treatment outcomes of extrapulmonary TB according to renal function. Methods: This retrospective study reviewed the medical records of patients diagnosed with extrapulmonary TB between January 2003 and December 2007. We classified the patients into two groups using the glomerular filtration rate (eGFR), estimated using the Modification of Diet in Renal Disease (MDRD) formula cut-off of 60 mL/min/1.73 m2 and evaluated their clinical features, treatment outcome and mortality (Group I vs. Group II, ≥ 60 mL/min/1.73 m2). Results: The mean eGFR of Groups I (n=30) and II (n=312) was 34±19 and 102±26 mL/min/1.73 m2, respectively. The pleura was the most frequent site of TB in both groups (Group I, 30.0% vs. Group II, 28.2%; p=0.379). There was no treatment failure or recurrence in either group. The mortality was higher in Group I (22.2% vs. 2.8%; p<0.01). In a multivariate analysis, eGFR<60 mL/min/1.73 m2 was an independent risk factor for mortality (HR=11.51, CI 2.512-52.741; p=0.002). Conclusions: Mortality related to extrapulmonary TB was higher in patients with impaired kidney function and kidney function was an independent predictor. However, there was no difference in treatment failure and recurrence according to renal function.
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