不同病原学检测方法在肾移植受者活动性结核病中的诊断效能

Diagnostic efficacy of different pathogen detection methods in active tuberculosis of kidney transplant recipients

摘要

目的 评估不同病原学检测方法在肾移植受者（KTR）活动性结核病（ATB）中的诊断效能并分析其在不同类型临床标本中的诊断价值。方法 采用回顾性观察性研究，纳入解放军总医院第八医学中心2020年1月至2025年1月期间疑似ATB的成年KTR。收集并分析受者基线资料，以复合参考标准（包括临床诊断和细菌学确诊）为诊断标准，比较抗酸染色涂片、结核分枝杆菌培养、结核分枝杆菌核酸及利福平耐药基因检测（Xpert MTB/RIF）及结核或非结核分枝杆菌DNA检测的单次检测效能，并分析不同方法间灵敏度差异。结果 纳入95例疑似ATB的KTR、136份标本，52例被确诊为ATB，其中48例为细菌学确诊（92%）。Xpert MTB/RIF和DNA检测的灵敏度（0.55和0.52）高于抗酸染色涂片（0.30）和结核分枝杆菌培养（0.35）（ P<0.01）。不同标本类型的细菌学确诊率差异有统计学意义（ P=0.035），脓液、穿刺组织和肺泡灌洗液的各方法检测灵敏度最高，痰液和胸腹腔积液次之，脑脊液最低。结论 核酸扩增技术用于免疫抑制的KTR灵敏度有所降低，仍应推荐其作为首选的初始筛查工具。采用“多部位采样（优先获取高细菌载量标本）联合多方法检测”的综合策略，可提高诊断效能。

Abstract

Objective To evaluate the diagnostic efficacy of different pathogen detection methods in active tuberculosis (ATB) of kidney transplant recipients (KTRs) and analyze their diagnostic value in different types of clinical specimens. Methods A retrospective observational study was conducted, including adult KTRs with suspected ATB from the Eighth Medical Center of Chinese People's Liberation Army General Hospital from January 2020 to January 2025. Baseline data of the recipients were collected and analyzed, and the diagnostic criteria were based on a composite reference standard (including clinical diagnosis and bacteriological confirmation). The single-detection efficacy of acid-fast staining smear, mycobacterium tuberculosis culture, Xpert test for the detection of mycobacterium tuberculosis nucleic acid and resistance to rifampicin (Xpert MTB/RIF), as well as tuberculosis or non-tuberculosis mycobacterial DNA detection was compared. The differences in sensitivity among different methods were analyzed. Results A total of 95 KTRs with suspected ATB and 136 specimens were included. And 52 cases were diagnosed as ATB, among which 48 cases were confirmed by bacteriological means (92%). The sensitivity of Xpert MTB/RIF and DNA detection (0.55 and 0.52, respectively) was significantly higher than that of acid-fast staining smear (0.30) and mycobacterium tuberculosis culture (0.35) ( P < 0.01). There was a statistically significant difference in the bacteriological diagnosis rate among different specimen types ( P = 0.035). The detection sensitivity of each method was the highest in pus, puncture tissue and bronchoalveolar lavage fluid, followed by sputum and pleural and abdominal effusions, and the lowest in cerebrospinal fluid. Conclusions The sensitivity of nucleic acid amplification technology for immunosuppressed KTRs is slightly reduced, but it should still be recommended as the preferred initial screening tool. The comprehensive strategy of "multi-site sampling (prior to obtaining high bacterial load specimens) combined with multiple method detection" may improve the diagnostic efficacy.

关键词

肾移植受者 / 活动性结核病 / 核酸扩增技术 / 结核分枝杆菌核酸及利福平耐药基因检测 / 抗酸染色涂片 / 结核分枝杆菌培养 / 诊断价值 / 标本类型

Key words

Kidney transplant recipient / Active tuberculosis / Nucleic acid amplification technology / Xpert test for the detection of mycobacterium tuberculosis nucleic acid and resistance to rifampicin / Acid-fast staining smear / Mycobacterium tuberculosis culture / Diagnostic value / Specimen type

参考文献

[1] MAMISHI S, POURAKBARI B, MORADZADEH M, et al. Prevalence of active tuberculosis infection in transplant recipients: a systematic review and meta-analysis[J]. Microb Pathog, 2020, 139: 103894. DOI: 10.1016/j.micpath.2019.103894.

[2] KATRAK S, HAN E, READHEAD A, et al. Solid organ transplant recipients with tuberculosis disease in California, 2010 to 2020[J]. Am J Transplant, 2023, 23(3): 401-407. DOI: 10.1016/j.ajt.2022.11.019.

[3] ALMEIDA VIANA L, CRISTELLI M P, SANTOS D W, et al. Influence of epidemiology, immunosuppressive regimens, clinical presentation, and treatment on kidney transplant outcomes of patients diagnosed with tuberculosis: a retrospective cohort analysis[J]. Am J Transplant, 2019, 19(5): 1421-1431. DOI: 10.1111/ajt.15220.

[4] BOEHME C C, NABETA P, HILLEMANN D, et al. Rapid molecular detection of tuberculosis and rifampin resistance[J]. N Engl J Med, 2010, 363(11): 1005-1015. DOI: 10.1056/nejmoa0907847.

[5] World Health Organization. Policy statement: automated real-time nucleic acid amplification technology for rapid and simultaneous detection of tuberculosis and rifampicin resistance: Xpert MTB/RIF system[M]. Geneva: World Health Organization, 2011.

[6] World Health Organization. WHO consolidated guidelines on tuberculosis. module 3: diagnosis - rapid diagnostics for tuberculosis detection 2021 update[EB/OL]. （ 2021-09-06）[2026-03-10]. https://iris.who.int/handle/10665/342331.

[7] 中华医学会器官移植学分会. 中国肾移植受者结核病临床诊疗指南（2023版）[J]. 器官移植, 2024, 15(3): 323-332. DOI: 10.3969/j.issn.1674-7445.2024098.

[8] Branch of Organ Transplantation of Chinese Medical Association . Guideline for clinical diagnosis and treatment of tuberculosis in kidney transplant recipients in China(2023 edition)[J]. Organ Transplant, 2024, 15(3): 323-332. DOI: 10.3969/j.issn.1674-7445.2024098.

[9] SU Q, XIAO J, PENG Z, et al. Analysis of the clinical characteristics of 100 patients who developed tuberculosis after renal transplantation[J]. BMC Infect Dis, 2025, 25(1): 795. DOI: 10.1186/s12879-025-11197-7.

[10] 肖东楼 . 中国结核病防治规划实施工作指南（2008年版）[M]. 北京: 中国协和医科大学出版社, 2009.

[11] 赵雁林, 刘志敏 . 结核病实验室标准化操作与网络建设[M]. 北京: 人民卫生出版社, 2013.

[12] World Health Organization. Consolidated guidance on tuberculosis data generation and use: module 1: tuberculosis surveillance[EB/OL]. (2024-01-02) [2026-03-10]. https://iris.who.int/handle/10665/376612.

[13] World Health Organization. Global tuberculosis report 2023[R/OL]. (2023-03-02) [2026-03-10]. https://iris.who.int/handle/10665/373828.

[14] CHAKRAVORTY S, SIMMONS A M, ROWNEKI M, et al. The new xpert MTB/RIF ultra: improving detection of Mycobacterium tuberculosis and resistance to rifampin in an assay suitable for point-of-care testing[J]. mBio, 2017, 8(4): e00812-e00817. DOI: 10.1128/mbio.00812-17.

[15] KOHLI M, INBARAJ L R, SALOMON A, et al. Low-complexity automated nucleic acid amplification tests for extrapulmonary tuberculosis and rifampicin resistance in adults and adolescents[J]. Cochrane Database Syst Rev, 2025, 8(8): CD012768. DOI: 10.1002/14651858.cd012768.pub4.

[16] PEÑATA A, SALAZAR R, CASTAÑO T, et al. Molecular diagnosis of extrapulmonary tuberculosis and sensitivity to rifampicin with an automated real-time method[J]. Biomedica, 2016, 36: 78-89. DOI: 10.7705/biomedica.v36i3.3088.

[17] 冯菁楠, 高乐, 孙一鑫, 等 . Xpert® MTB/RIF对我国人群活动性肺结核和利福平耐药肺结核诊断准确性的meta分析[J]. 北京大学学报（医学版）, 2021, 53(2): 320-326. DOI: 10.19723/j.issn.1671-167X.2021.02.015.

[18] FENG J N, GAO L, SUN Y X, et al. Accuracy of Xpert(R) MTB/RIF for the detection of tuberculosis and rifampicinresistance tuberculosis in China: a systematic review and meta-analysis[J]. J Peking Univ Health Sci, 2021, 53(2): 320-326. DOI: 10.19723/j.issn.1671-167X.2021.02.015.

[19] URBANOWSKI M E, ORDONEZ A A, RUIZ-BEDOYA C A, et al. Cavitary tuberculosis: the gateway of disease transmission[J]. Lancet Infect Dis, 2020, 20(6): e117-e128. DOI: 10.1016/S1473-3099(20)30148-1.

[20] ROZENSHTEIN A, HAO F, STARC M T, et al. Radiographic appearance of pulmonary tuberculosis: dogma disproved[J]. Am J Roentgenol, 2015, 204(5): 974-978. DOI: 10.2214/ajr.14.13483.

[21] PEREIRA M, GAZZONI FF, MARCHIORI E, et al. High-resolution CT findings of pulmonary Mycobacterium tuberculosis infection in renal transplant recipients[J]. Br J Radiol, 2016, 89(1058): 20150686. DOI: 10.1259/bjr.20150686.

[22] KAY A W, GONZÁLEZ FERNÁNDEZ L, TAKWOINGI Y, et al. Xpert MTB/RIF and Xpert MTB/RIF Ultra assays for active tuberculosis and rifampicin resistance in children[J]. Cochrane Database Syst Rev, 2020, 8(8): CD013359. DOI: 10.1002/14651858.cd013359.pub2.

[23] PANG Y, AN J, SHU W, et al. Epidemiology of extrapulmonary tuberculosis among inpatients, China, 2008-2017[J]. Emerg Infect Dis, 2019, 25(3): 457-464. DOI: 10.3201/eid2503.180572.

[24] GONG X, HE Y, ZHOU K, et al. Efficacy of Xpert in tuberculosis diagnosis based on various specimens: a systematic review and meta-analysis[J]. Front Cell Infect Microbiol, 2023, 13: 1149741. DOI: 10.3389/fcimb.2023.1149741.

[25] KUMAR A, SINGH A K, GAUR V, et al. Diagnostic modalities for detecting extrapulmonary tuberculosis and resistance patterns of rifampicin and isoniazid at a referral hospital: a retro prospective study[J]. Int J Mycobacteriol, 2025, 14(2): 110-116. DOI: 10.4103/ijmy.ijmy_17_25.

[26] INBARAJ L R, SRINIVASALU V A, SATHYA NARAYANAN M K, et al. Diagnostic accuracy of low-complexity, manual nucleic acid amplification tests for the detection of pulmonary and extrapulmonary tuberculosis in adults and adolescents: a systematic review and meta-analysis[J]. Lancet Microbe, 2025, 6(10): 101169. DOI: 10.1016/j.lanmic.2025.101169.

[27] OTIENO J A, WERE L M, LUTJE V, et al. Impact of rapid nucleic acid amplification tests for tuberculosis on patient outcomes[J]. Cochrane Database Syst Rev, 2025(12): CD016194. DOI: 10.1002/14651858.cd016194.

[28] CHEN Y Z, SUN L C, WEN Y H, et al. Pooled analysis of the Xpert MTB/RIF assay for diagnosing tuberculous meningitis[J]. Biosci Rep, 2020, 40: BSR20191312. DOI: 10.1042/bsr20191312.

[29] WANG C, FORSMAN L D, WANG S, et al. The diagnostic performance of GeneXpert MTB/RIF in tuberculosis meningitis: a multicentre accuracy study[J]. Diagn Microbiol Infect Dis, 2024, 109(3): 116277. DOI: 10.1016/j.diagmicrobio.2024.116277.

[30] POORE H, WAMBI P, NKEREUWEM E, et al. The three-gene xpert host response signature for pediatric tuberculosis screening: a prospective diagnostic accuracy study[J]. Clin Infect Dis, 2025, 81(5): e424-e431. DOI: 10.1093/cid/ciaf445.

[31] MALHOTRA A G, LOKHANDE L, PAKHARE A, et al. Diagnostic yield of Xpert MTB/RIF, Xpert MTB/RIF Ultra, and Truenat MTB assays on non-pulmonary samples from suspected cases of extra-pulmonary tuberculosis (EPTB)[J]. Eur J Clin Microbiol Infect Dis, 2025, 44(9): 2093-2103. DOI: 10.1007/s10096-025-05177-7.

[32] CUELLA-MARTIN I, HAKIZAYEZU F, AHMED A, et al. Paucibacillary tuberculosis drives the low positive predictive value of xpert MTB/RIF ultra for rifampicin resistance detection in low-prevalence settings[J]. Clin Infect Dis, 2025, 81(2): 372-378. DOI: 10.1093/cid/ciaf132.

[33] KASULE G W, HERMANS S, ACACIO S, et al. Performance of stool Xpert MTB/RIF Ultra for detection of Mycobacterium tuberculosis among adults living with HIV: a multicentre, prospective diagnostic study[J]. Lancet Microbe, 2025, 6(7): 101085. DOI: 10.1016/j.lanmic.2025.101085.

[34] CARRATALÀ-CASTRO L, MUNGUAMBE S, SAAVEDRA-CERVERA B, et al. Performance of stool-based molecular tests and processing methods for paediatric tuberculosis diagnosis: a systematic review and meta-analysis[J]. Lancet Microbe, 2025, 6(6): 100963. DOI: 10.1016/j.lanmic.2024.100963.

[35] BELEW H, TILAHUN A, FENTA A, et al. Diagnostic accuracy of stool based Xpert MTB/RIF ultra assay for diagnosis of pulmonary tuberculosis in children, Northwest Ethiopia[J]. Sci Rep, 2025, 15: 39408. DOI: 10.1038/s41598-025-22111-1.

[36] WANG Y, GUO P, CHEN Y, et al. Comparison and evaluation of metagenomic next-generation sequencing (mNGS) and real-time PCR for the detection of Mycobacterium tuberculosis[J]. Front Cell Infect Microbiol, 2025, 15: 1694179. DOI: 10.3389/fcimb.2025.1694179.

[37] WU S, WANG S, WU Z, et al. Comparative analysis of the clinical characteristic and lung microbiota in adult and elderly patients with pulmonary tuberculosis[J]. Sci Rep, 2025, 15: 19777. DOI: 10.1038/s41598-025-04970-w.

[38] XIAO H, ZHOU C, XIAO Z, et al. Metagenomic next-generation sequencing of bronchoalveolar lavage fluid samples offers diagnostic utility in bacteriologically negative pulmonary tuberculosis[J]. Diagn Microbiol Infect Dis, 2025, 111(4): 116725. DOI: 10.1016/j.diagmicrobio.2025.116725.

[39] MIAO M, MA C, YANG J, et al. BALF metagenomic next-generation sequencing for the diagnosis of pulmonary mycobacterial infection in persons with HIV: a retrospective, diagnostic accuracy study[J]. Front Microbiol, 2025, 16: 1689997. DOI: 10.3389/fmicb.2025.1689997.

[40] CHEN Y, TANG H, ZHENG J, et al. Transforming tuberculosis diagnosis with clinical metagenomics: progress and roadblocks[J]. J Clin Microbiol, 2025, 63(12): e00537-e00525. DOI: 10.1128/jcm.00537-25.

基金资助

国家自然科学基金(32271411)