CRA95 CHALLENGES IN TUBERCULOSIS TREATMENT IN CKD: A COMPARATIVE CASE SERIES OF DRUG DOSING STRATEGIES AND PATIENT OUTCOMES

Sari Handayani Utami,¹ Irvan Medison²,Dewi Wahyu Fitrina¹, Dessy Mizarti²

¹Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Andalas University Andalas, Padang, West Sumatra, Indonesia
²Department of Pulmonology and Respiratory Medicine, Dr. M. Djamil General Hospital, Padang, West Sumatera, Indonesia

Introduction
Patients with chronic kidney disease (CKD) undergoing haemodialysis have a higher risk of suffering tuberculosis (TB). Management TB on CKD depends on severity of renal function.

Case illustration
First case: A 41-year-old female patient had already known as stage V CKD patient on regular haemodialysis (HD) got bacteriological confirmed lung tuberculosis. She received a customized antituberculosis drug regimen that is full doses of rifampicin and isoniazid, while the doses of ethambutol and pyrazinamide were adjusted to three times a week during the intensive phase, followed by a continuation phase with 2 Fixed Dose Combination (FDC) everyday until the ninth month. Clinical response was good, marked by improvement in chest X-ray and weight gain.

Second case: A 48-year-old female patient had already known as stage V CKD on HD with relapse bacteriological confirmed lung tuberculosis. She received full-dose 4FDC followed by two FDCs in the continuation phase. Renal function deteriorated at the start of the intensive phase. She gained weight, but chest X-rays did not show significant improvement.

Discussion
The first patient was given a special dose-adjusted anti-TB drugs for ethambutol and pyrazinamide. Ethambutol and pyrazinamide are excreted by kidneys so need adjustment to minimise side effects especially for renal function. The second patient show worsening renal function at the beginning. Chest X-ray evaluation showed improvement after the ninth month, a little longer if compared to the first patient.

Conclusion
Management of TB patients with CKD on HD requires special consideration. Nephrotoxic anti-TB drugs such as ethambutol and pyrazinamide require dose adjustment, as both drugs can worsen renal function.