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Meta-Analysis
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The Impact of Diabetes on Tuberculosis Treatment Outcomes: A Systematic Review

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Meta-Analysis

The Impact of Diabetes on Tuberculosis Treatment Outcomes: A Systematic Review

Meghan A Baker et al. BMC Med.

Abstract

Background: Multiple studies of tuberculosis treatment have indicated that patients with diabetes mellitus may experience poor outcomes.We performed a systematic review and meta-analysis to quantitatively summarize evidence for the impact of diabetes on tuberculosis outcomes.

Methods: We searched PubMed, EMBASE and the World Health Organization Regional Indexes from 1 January 1980 to 31 December 2010 and references of relevant articles for reports of observational studies that included people with diabetes treated for tuberculosis. We reviewed the full text of 742 papers and included 33 studies of which 9 reported culture conversion at two to three months, 12 reported the combined outcome of failure and death, 23 reported death, 4 reported death adjusted for age and other potential confounding factors, 5 reported relapse, and 4 reported drug resistant recurrent tuberculosis.

Results: Diabetes is associated with an increased risk of failure and death during tuberculosis treatment. Patients with diabetes have a risk ratio (RR) for the combined outcome of failure and death of 1.69 (95% CI, 1.36 to 2.12). The RR of death during tuberculosis treatment among the 23 unadjusted studies is 1.89 (95% CI, 1.52 to 2.36), and this increased to an effect estimate of 4.95 (95% CI, 2.69 to 9.10) among the 4 studies that adjusted for age and other potential confounding factors. Diabetes is also associated with an increased risk of relapse (RR, 3.89; 95% CI, 2.43 to 6.23). We did not find evidence for an increased risk of tuberculosis recurrence with drug resistant strains among people with diabetes. The studies assessing sputum culture conversion after two to three months of tuberculosis therapy were heterogeneous with relative risks that ranged from 0.79 to 3.25.

Conclusions: Diabetes increases the risk of failure and death combined, death, and relapse among patients with tuberculosis. This study highlights a need for increased attention to treatment of tuberculosis in people with diabetes, which may include testing for suspected diabetes, improved glucose control, and increased clinical and therapeutic monitoring.

Figures

Figure 1
Figure 1
The literature search for studies on the association between DM and TB outcomes.
Figure 2
Figure 2
Risk of remaining sputum culture positive for TB patients with DM compared with TB patients without DM. Size of the square is proportional to the precision of the study-specific effect estimates, and the bars indicate the corresponding 95% CIs. *The RR for Guler et al. [40] was calculated using the OR, CI and total number of patients with and without DM provided in the paper.
Figure 3
Figure 3
Risk of failure/death for TB patients with DM compared with TB patients without DM. Size of the square is proportional to the precision of the study-specific effect estimates, and the bars indicate the corresponding 95% CIs. The diamond is centered on the summary RR of the observational studies, and the width indicates the corresponding 95% CI.
Figure 4
Figure 4
Risk of death for TB patients with DM compared with TB patients without DM. Size of the square is proportional to the precision of the study-specific effect estimates, and the bars indicate the corresponding 95% CIs. The diamond is centered on the summary RR of the observational studies, and the width indicates the corresponding 95% CI.
Figure 5
Figure 5
Adjusted odds of death for TB patients with DM compared with TB patients without DM. Size of the square is proportional to the precision of the study-specific effect estimates, and the bars indicate the corresponding 95% CIs. The diamond is centered on the summary OR of the observational studies, and the width indicates the corresponding 95% CI.
Figure 6
Figure 6
Risk of TB relapse for TB patients with DM compared with TB patients without DM. Size of the square is proportional to the precision of the study-specific effect estimates, and the bars indicate the corresponding 95% CIs. The diamond is centered on the summary RR of the observational studies, and the width indicates the corresponding 95% CI.
Figure 7
Figure 7
Odds of recurrent TB that is DR, comparing patients with DM to patients without DM. Size of the square is proportional to the precision of the study-specific effect estimates, and the bars indicate the corresponding 95% CIs. The diamond is centered on the summary OR of the observational studies, and the width indicates the corresponding 95% CI.

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