The International Journal of Artificial Organs / Vol. 19/ no. 8,1996/ pp. 441-445 Editorial Fungal peritonitis in continuous ambulatory peritoneal dialysis Peritonitis causes considerable morbidity in peritoneal dialysis patients, It accounts for most of the catheters lost and is the main reason for transfer to hemodialysis on a temporary or sometimes permanent basis. When severe it requires hospitalization. Oeath may result either from sepsis or from related complications. In the past decade, much progress has been made in reducing the rate of CAPO peritonitis to about one episode every 24 patient months (1); however it still remains a formidable problem. The frequency of bacterial peritonitis has diminished with the introduction of V-systems and other advances in connectology. The impact of these advances has not been felt on fungal peritonitis, which still accounts for 1.5-10% of all peritonitis (2, 3). In the Far East its incidence has been as high as 15% (4). Overall it accounts for 8% of initial no growth peritonitis (5). Some authors believe that the pro- portional incidence of fungal peritonitis has been stable (6). Though relatively uncommon, fungal peritonitis is important because it causes a disproportionately higher morbidity and mortality; the latter may be as high as 17- 25% (3, 4, 7). There is a higher incidence of catheter loss and peritoneal adhesions, with resultant transfer to hemo- dialysis. Several factors predispose to fungal peritonitis. The most consistently correlated is prior antibiotic use (3). The antibiotics are frequently given for bacterial peritonitis and exit site infections, though their use for other infections has also been implicated. Candida species have been iso- lated in the fecal flora following antimicrobial therapy (8). Transmural migration of intestinal organism after perito- neal irrigation was documented in dogs (9). Conceivably antimicrobial therapy causes alteration of fecal flora, trans- migration into the peritoneal cavity and, in the immuno- compromised host, growth of fungi. Age, sex, the type of renal disease, and diabetes did not correlate significantly with the development of FP. However, being on immuno- suppressive therapy did (3). HIV positive patients (10) also have a high incidence of fungal peritonitis. Intra catheter instillation of streptokinase likewise increases the risk of infection (11). There are reports of fungal peritonitis occur- ring after fecal peritonitis (2) or infection via the vaginal route (2). Coccidioidal peritonitis has been described in association with pulmonary infections (12), and cryptococ- cal with meningeal (13); however, the occurrence of PO fungal peritonitis with disseminated fungal infection is uncommon. The mechanism by which fungi, which are normal human commensals and non pathogenic, cause infection remains largely unexplored. A break in the normal barriers by the peritoneal catheter and the presence of peritoneal fluid contribute. Akin to bacterial peritonitis, impaired cellu- lar host defence via impaired polymorphonuclear phagocy- tosis and intracellular killing plays a role in fungal peritoni- tis. The fungus colonizes the peritoneal catheter; electron microscopy of removed PO catheters has shown organi- sms embedded in an amorphous matrix on the surface of the catheters (14), thus rendering successful antifungal therapy difficult. Candida albicans is the commonest cause of fungal peri- tonitis, causing 75% of all cases (3). Other candida species such as C. guillermondii, C. krusei, C. tropicalis, and C. parapsilosis have also been isolated. An outbreak of fungal peritonitis due to Candida parapsilosis in 12 patients was traced to pigeon droppings obtained from the window-sills of a CAPO unit. Installation of bird-proof netting effectively limited further occurrences (15). Other yeasts that are rarely causal are Coccidioidomycoses immitis (12), Cryp- tococcus neoformans (13), Rhodotorula rubra (2), and Torulopsis glabrata (16). They probably enter the perito- neal cavity via the peritoneal catheter, intraluminally or peri-Iuminally. Filamentous fungi rarely contaminate the catheter and cause peritoneal infections (8, 17-22). Most infections due to these agents are resistant to antifungal agents, hence catheters are removed early. Other fungi may rarely cause peritonitis. These include Coccidioides immitis (12) Cryp- tococcus neoformans (13), Rhizopus species (21), Asper- gillus species (22), Alternaria (23), Fusarium moniliform (24), Curvularia lunata (25), syncephalastrum (26), Paeci- lomyces variotii (27), Exophiala jeanselmei (28), and Wan- giella dermatidis (29). Curvularia lunata can cause perito- nitis as well as isolated catheter obstruction without perito- nitis (2). Fungal peritonitis may present with cloudy bags, abdo- minal pain and fever, features identical to bacterial and sterile peritonitis (30, 35). The white cell count varies from 90 to 10,000 per cubic millimeter, with polymorphs accounting for 2-98% of the cells (3). In 10% of cases © by Wichtig Editore, 1996 0391-3988/441-05 $02.50/0