Dialysate color and its role in presumptive diagnosis of dimorphic fungi in peritoneal dialysis associated fungal peritonitis


  • Upma Narain Department of Microbiology, Tejas Microdiagnostics, Allahabad, Uttar Pradesh, India
  • Arvind Gupta Department of Nephrology, Moti Lal Nehru Medical College, Allahabad, Uttar Pradesh, India




CAPD, Color of dialysate, Dimorphic fungi, End stage renal disease, Fungal peritonitis, Predictors


Background: Fungal peritonitis is a rare but serious complication of peritoneal dialysis (PD). Dimorphic fungi are described in peritonitis at a much lower percentage than yeasts are, but their involvement in it is growing.

Methods: The study was based on the analysis of available data over a period of 16 years. The sample size was of 421 ESRD patients on CAPD. We retrospectively identified 72 cases of fungal peritonitis. In the present study we assessed the frequency of dimorphic fungi as a single pathogen, its association with the dialysate colour along with the predictors and its impact on the outcome of the patients.

Results: In between January 2000 and October 2016, in present retrospective study, we identified 72 episodes of peritoneal dialysis associated with fungal peritonitis. Among the 72 fungal episodes, 83.3% were Candida species, 1.5% were yeast and the remaining 15.2% were dimorphic fungi. The macrolevel observations of dialysate showed greyish, blackish, greenish, pinkish, cloudy, bluish green and cloudy colours that developed due to the pigmentation of fungi and fungal spores. The Aspergillus species predominates amongst the dimorphic fungi. Outcome analysis revealed that the loss of life (14.7%) was more frequent in diabetics while the reinsertion of catheter failed in cases of glomerulonephritis. It was also noticed that de novo infections were more frequent among the diabetics and that the previous bacterial peritonitis episode was the strongest predictor amongst them all.

Conclusions: The premise of the current study illustrates the fact that the dialysate colour can be put to use as an early warning system and by combining the macroscopic observations of the dialysate with the results of microscopy and culture, the diagnosis of Fungal peritonitis due to dimorphic fungi will not be missed. Also worth noting is the point that an early assessment of predictors alongside that of an antifungal coverage can lead to a reduction in the rates of morbidity which in turn will shorten the stay in hospital. This will prevent any further nosocomial infection, antifungal resistance and chances of treatment failure.


Matuszkiewicz-Rowinska J. Update on fungal peritonitis and its treatment. Perit Dial Int. 2009;29(S2):S161-5.

Agudo RG, Martos PG. Clinical and microbiological aspects of fungal peritonitis in peritoneal dialysis. Nefrologia. 2009;29(6):506-17.

Prasad N, Gupta A. Fungal peritonitis in peritoneal dialysis patients. Perit Dial Int. 2005;25:207-22.

Bibashi E, Memmos D, Kokolina E, Tsakiris D, Sofianou D, Papadimitriou M. Fungal peritonitis complicating peritoneal dialysis during an 11-year period: report of 46 cases. Clin Infect Dis. 2003;36:927-31.

Li PK, Szeto CC, Piraino B, Bernardini J, Figueiredo AE, Gupta A, et al. Peritoneal dialysis-related infections recommendations: 2010 [Update]. Perit Dial Int. 2010;30:393-423.

Li PK, Szeto CC, Piraino B, de Arteaga J, Fan S, Figueiredo AE, et al. ISPD peritonitis recommendations: 2016 update on prevention and treatment. Perit Dial Int. 2016;36(5):481-508.

Kuen KY, Seto WH, Ching TY, Cheung WC, Kwok Y, Chu YB. An outbreak of Candida tropicalis peritonitis in patients on intermittent peritoneal dialysis. J Hosp infect. 1992;22:65-72.

Narain U, Gupta A. Role of predictors and rapid diagnosis of fungal peritonitis in CAPD patients. Int J Adv Med. 2016;3(1):130-5.

Narain U, Gupta A. Peritoneal dialysis related Candida peritonitis: a 16-year single-centre experience. Arch Clin Microbiol. 2016;7:2.

Indhumathi E, Chandrasekaran V, Jagadeswaran D, Varadarajan M, Abraham G, Soundararajan P. The risk factors and outcome of fungal peritonitis in continuous ambulatory peritoneal dialysis patients. Indian J Med Microbiol. 2009;27:59-61.

Wang AYM, Yu AWY, Li PKT, Lam PKW, Leung CB, Lai KN, et al. Factors predicting outcome of fungal peritonitis in peritoneal dialysis: analysis of a 9-year experience of fungal peritonitis in a single center. Am J Kidney Dis. 2000;36(6):1183-92.

Yang DC, Wang MC, Lin WH, Wu AB, Sung JM, Cheng MF, et al. Peritoneal dialysis-related fungal peritonitis: twenty-year experience of a medical center in Southern Taiwan. Acta Nephrologica. 2012;26(3):149-54.

Bibashi E, Memmos D, Kokolina E, Tsakiris D, Sofianou D, Papadimitriou M. Fungal peritonitis complicating peritoneal dialysis during an 11-year period: report of 46 cases. Clin Infect Dis. 2003;36:927-30.

Predari SC, De Paulis AN, Verón D, Zucchini A, Santoianni JE. Fungal peritonitis in patients on peritoneal dialysis: twenty-five years of experience in a teaching hospital in Argentina. Rev Argent Microbiol. 2007;39:213-7.

Greig J, Harkness M, Taylor P, Hashmi C, Liang S, Kwan J. Peritonitis due to the dermatiaceous mold Exophiala dermatitidis complicating continuous ambulatory peritoneal dialysis. Clin Microbiol Infect. 2003;9:713-5.

Lopes JO, Alves SH, Benevenga JP, Brauner FB, Castro MS, Melchiors E. Curvularia lunata peritonitis complicating peritoneal dialysis. Mycopathologia. 1994;127:65-7.

Vogelgesang SA, Lockard JW, Quinn MJ, Hasbargen JA. Alternaria peritonitis in a patient undergoing continuous ambulatory peritoneal dialysis. Perit Dial Int. 1990;10:313.

Reiss-Levy E, Clingan P. Peritonitis caused by Alternaria alternata. Med J Aust. 1981;2:44.

Bava AJ, Fayad A, Céspedes C, Sandoval M. Fungal peritonitis caused by Bipolaris spicifera. Med Mycol 2003;41:529-31.

Gadallah MF, White R, El-Shahawy MA, Abreo F, Oberle A, Work J. Peritoneal dialysis complicated by Bipolaris hawaiiensis peritonitis: successful therapy with catheter removal and oral itraconazol without the use of amphotericin-B. Am J Nephrol. 1995;15:348-52.

Mise N, Ono Y, Kurita N, Sai K, Nishi T, Tagawa H, et al. Aureobasidium pullulans peritonitis: case report and review of the literature. Perit Dial Int. 2008;28:679-81.

Caporale NE, Calegari L, Perez D, Gezuele E. Peritoneal catheter colonization and peritonitis with Aureobasidium pullulans. Perit Dial Int. 1996;16:97-8.

Severo LC, Oliveira F, Garcia CD, Uhlmann A, Londero AT. Peritonitis by Scedosporium apiospermum in a patient undergoing continuous ambulatory peritoneal dialysis. Rev Inst Med Trop Sao Paulo. 1999;41:263-4.

Vaidya PS, Levine JF. Scopulariopsis peritonitis in a patient undergoing continuous ambulatory peritoneal dialysis. Perit Dial Int. 1992;12:78-9.

Chen CM, Ho MW, Yu WL, Wang JH. Fungal peritonitis in peritoneal dialysis patients: effect of fluconazole treatment and use of the twin-bag disconnect system. J Microbiol Immunol Infect. 2004;37:115-20.

Esel D, Koc AN, Utas C, Karaca N, Bozdemir N. Fatal peritonitis due to Trichoderma sp. in a patient undergoing continuous ambulatory peritoneal dialysis. Mycoses. 2003;46:71-3.

Tanis BC, Van der Pijl H, Van Ogtrop ML, Kibbelaar RE, Chang PC. Fatal fungal peritonitis by Trichoderma longibrachiatum complicating peritoneal dialysis. Nephrol Dial Transplant. 1995;10:114-6.

Febré N, Silva V, Medeiros EA, Godoy P, Reyes E, Halker E, et al. Contamination of peritoneal dialysis fluid by filamentous fungi. Rev Iberoam Micol. 1999;16:238-9.

Ahmad S, Johnson RJ, Hillier S, Shelton WR, Rinaldi MG. Fungal peritonitis caused by Lecythophora mutabilis. J Clin Microbiol. 1985;22:182-6.

Shin JH, Lee SK, Suh SP, Ryang DW, Kim NH, Rinaldi MG, et al. Fatal Hormonema dematioides peritonitis in a patient on continuous ambulatory peritoneal dialysis: criteria for organism identification and review of other known fungal etiologic agents. J Clin Microbiol. 1998;36:2157-63.

Amici G, Grandesso S, Mottola A, Virga G, Teodori T, Maresca MC, et al. Verticillium peritonitis in a patient on peritoneal dialysis. Am J Nephrol. 1994;14:216-9.






Original Research Articles