SUMMARYLatent tuberculosis infection (LTBI) is common and preventable among patients with chronic kidney disease (CKD), where uremia and iatrogenic immunosuppression heighten reactivation risk. This narrative review synthesizes evidence across pre-dialysis CKD, dialysis, and kidney transplantation to propose a pragmatic care pathway. In advanced CKD, the tuberculin skin test performs poorly, whereas interferon-γ release assays (IGRAs) are preferred. Screening should be risk-targeted in pre-dialysis CKD, systematic at dialysis initiation, and mandatory pre-transplant for candidates and living donors. Following a positive test, clinicians must exclude active tuberculosis via clinical assessment and chest imaging before starting preventive therapy. Short-course rifamycin-based regimens (4 months of daily rifampin 4R, 3 months of once‑weekly isoniazid plus rifapentine 3HP, or 3 months of daily isoniazid plus rifampin 3HR) enhance completion rates compared with 9 months of daily isoniazid (9H). In transplant recipients, rifamycin interactions with calcineurin and Mammalian target of rapamycin (mTOR) inhibitors typically favor 9H; rifamycins demand expert multidisciplinary management with intensive therapeutic drug monitoring. Programmatic data from dialysis units show high completion with tolerable toxicity, affirming routine feasibility. We integrate IGRA-based screening at critical transitions with tailored regimen selection, pyridoxine coadministration for isoniazid, and structured safety monitoring. Priorities include validating novel Mycobacterium tuberculosis antigen-based skin tests in CKD and developing implementation strategies to standardize renal care. We delineate setting-specific approaches for high- versus low-burden countries, addressing subclinical and incipient TB challenges in high-burden contexts. Adopting this framework can curb active TB progression, safeguard grafts, and enhance patient outcomes.
Chancharoenthana et al. (Mon,) studied this question.