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Part 5: Peritonitis |
Department of Nephrology, Dialysis and Internal Diseases, The Medical University of Warsaw, Warsaw, Poland
Correspondence to: J. Matuszkiewicz-Rowinska, Department of Nephrology, Dialysis and Internal Diseases, The Medical University of Warsaw, ul. Banacha 1a, Warsaw 02-097 Poland. jotmatrow{at}o2.pl
Fungal peritonitis (FP) is a rare but potentially fatal complication of
chronic peritoneal dialysis (PD), associated with high morbidity and mortality
ranging between 20% and 30%. If not leading to death, the inflammatory process
usually causes irreversible damage to the peritoneal membrane with subsequent
dropout from PD therapy. Fungal peritonitis accounts for 3% – 6% of all
peritonitis episodes; however, in some areas, the numbers can be much higher.
The most common cause of the disease is Candida, predominately C.
albicans, C. parapsilosis, and—more recently— C.
glabrata; other yeasts and filamentous fungi such as Aspergillus,
Paecilomyces, Penicillium, and Zygomycetes are found, but much
less frequently. The main factors associated with the development of FP
include previous antibiotic therapy, particularly for bacterial peritonitis,
when two important operative mechanisms coincide: fungal overgrowth in the
gastrointestinal tract and declining peritoneal defense because of
peritonitis.
The management of FP poses a difficult challenge. Prompt initiation of
therapy is critical, but no typical clinical picture has emerged, and the
infecting organism can be difficult to isolate. The approach to the disease
has changed considerably in recent years, and the 2005 guidelines from the
International Society for Peritoneal Dialysis list FP as a strong indication
for immediate catheter removal with temporary hemodialysis. The conventional
antifungal regimens include fluconazole, amphotericin B, and flucytosine alone
or in combination, optimally based on fungal sensitivities. The newer agents
such as caspofungin and voriconazole have the potential to alter treatment
strategies for FP, but further studies are required to clarify the precise
role of these agents in this group of patients.
KEY WORDS: Fungal peritonitis; peritonitis prophylaxis; peritoneal catheter removal.
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