Characteristics and outcomes of fungal peritonitis in a modern North American cohort.
BACKGROUND
Peritonitis remains a common complication of peritoneal dialysis (PD). Although representing only 1 - 12% of overall peritonitis in dialysis patients, fungal peritonitis (FP) is associated with serious complications, including technique failure and death. Only scarce data have been published regarding FP outcomes in modern cohorts in North America. In this study we evaluated the rates, characteristics and outcomes of FP in a major North American PD center.


METHODS
We conducted a retrospective cohort study including all fungal peritonitis episodes among peritoneal dialysis patients followed in a large PD center between January 2000 and February 2013. Our pre-specified endpoints included rates of FP, characteristics, outcomes and determinants of death.


RESULTS
Thirty-six episodes of FP were identified during the follow-up period (one episode per 671 patient-months), representing 4.5% of the total peritonitis events. Patients' mean age and peritoneal dialysis vintage were 61.3 ± 15.5 and 2.9 (1.5 - 4.8) years, respectively. Of the 36 episodes of FP, seven (19%) resulted in death and 17 (47%) led to technique failure with permanent transfer to hemodialysis. Surprisingly, PD was eventually resumed in 33% of cases with a median delay of 15 weeks (interquartile range 8 - 23) between FP and catheter reinsertion. In a univariable analysis, a higher Charlson comorbidity index (Odds ratio [OR] 3.25 per unit increase, 95% confidence interval [CI] 1.23 - 8.58) and PD fluid white blood cell (WBC) count greater than 3,000/mm(3) at presentation (OR 6.56, 95% CI 1.05 - 40.95) predicted death.


CONCLUSIONS
While fungal peritonitis is still associated with a high frequency of death and technique failure, one third of our patients eventually returned to PD. Patients with a high burden of comorbidities appear at higher risk of death. We postulate that the high mortality associated with FP is partially related to the severity of comorbidity among patients with FP, rather than the infection per se. Importantly, PD can be resumed in a significant proportion of cases.
Toronto General Hospital, University Health Network, Division of Nephrology, University of Toronto, Toronto, Ontario, Canada.
Annie-Claire
AC
Nadeau-Fredette
Toronto General Hospital, University Health Network, Division of Nephrology, University of Toronto, Toronto, Ontario, Canada.
Joanne M
JM
Bargman
D000046:Academic Medical Centers; D000368:Aged; D000935:Antifungal Agents / Q000008:administration & dosage*; D002408:Catheters, Indwelling / Q000009:adverse effects; D015331:Cohort Studies; D020878:Device Removal / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D009181:Mycoses / Q000188:drug therapy / Q000209:etiology / Q000401:mortality*; D009656:North America; D009864:Ontario; D063868:Patient Outcome Assessment; D010530:Peritoneal Dialysis / Q000009:adverse effects* / Q000379:methods / Q000401:mortality; D010538:Peritonitis / Q000209:etiology / Q000382:microbiology* / Q000401:mortality; D012189:Retrospective Studies; D018570:Risk Assessment; D015996:Survival Rate; D016896:Treatment Outcome
D000935:Antifungal Agents
Peritoneal dialysis; death; fungal peritonitis; technique survival