| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Clinical |
Renal Unit, Department of Medicine & Geriatrics, Kwong Wah Hospital, Hong Kong SAR, China
Correspondence to: P.N. Wong, Renal Unit, Department of Medicine & Geriatrics, Kwong Wah Hospital, 25 Waterloo Road, Kowloon, Hong Kong SAR, China. apnwong{at}alumni.cuhk.net
Background: Fungal peritonitis (FP) is associated with
significant mortality and high risk of peritoneal failure. The optimum
treatment for peritoneal dialysis (PD)-associated FP remains unclear. Since
January 2000 we have been treating FP with a combination of intravenous
amphotericin B and oral flucytosine, together with deferred catheter
replacement. We examined the clinical course and outcome of the FP patients
treated with this approach (study group). An outcome comparison was also made
to an alternatively treated historic cohort (control group). Methods: This was a single-center retrospective study.
The clinical course and outcome of 13 consecutive episodes of FP occurring in
13 patients treated between January 2000 and April 2005 with the study
approach were examined. The patients were treated with an incremental dose of
intravenous amphotericin B to a target dose of 0.75 – 1 mg/kg body
weight/day, and oral flucytosine 1 g/day upon a diagnosis of FP at 3.77
± 0.93 days from presentation. Replacement of the peritoneal catheter
was intended after complete clearing of effluent, after which, antifungal
chemotherapy was continued for another 1 – 2 weeks. Their outcome was
compared with 14 historic controls that were treated between April 1995 and
December 1999. Results: Mean age of the study group was 58.7 ±
13.2 years; male-to-female ratio was 2:11; 6 (46.1%) were diabetic. All FP
were caused by Candida species (C. albicans, 2; C.
parapsilosis, 8; C. glabrata, 3). Two (15.4%) patients died
before resolution of the peritonitis. The dialysate effluent cleared in 11
patients (84.6%) after 13.2 ± 3.3 days of treatment, but 2 patients
died of acute myocardial infarction before catheter replacement. Nine patients
had their catheters replaced at day 26.7 ± 7.7 of treatment; all 9
returned to PD after a total of 31 ± 12.2 days of antifungal
chemotherapy. Reversible liver dysfunction was common with this regimen. When
compared with the 14 cases in the historic control group (Candida
species, 13; Trichosporon, 1), who were treated with amphotericin B,
fluconazole, or a combination of the two, and the majority (78.6%) of whose
catheters were removed before day 10 of presentation, the study group appeared
to have a lower technique failure rate (30.8% vs 78.6%, p = 0.013)
and similar all-cause mortality (30.7% vs 28.5%, p = NS), FP-related
mortality (15.4% vs 28.5%, p = NS), and length of hospitalization
(48.5 ± 30.2 vs 57.0 ± 37.7 days, p = NS). However, a
significantly earlier commencement of antifungal treatment in the study group
(3.8 ± 0.9 vs 5.8 ± 2.4 days, p = 0.012) could be an
important confounder of outcome. Conclusions: Combination of intravenous amphotericin B
and oral flucytosine with deferred catheter replacement appears to be
associated with a relatively low incidence of PD technique failure, without
affecting mortality in patients suffering from FP due to yeasts in this
preliminary study. Nonetheless, drug-induced hepatic dysfunction was common;
close monitoring during treatment is of paramount importance. The reasons
accounting for the observed distinctive outcome remain unclear and further
study is required to confirm the results and to investigate for the underlying
mechanism.
KEY WORDS: Amphotericin B; catheter; flucytosine; fungal peritonitis; outcome.
Received 26 May 2007; accepted 7 November 2007.
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
 |
