Hypogammaglobulinaemia: cumulative experience in 49 patients in a tertiary care institution

In this paper, clinical data of 49 adult patients with agammaglobulinaemia (syn. hypogammaglobulinaemia), 15 cases of X-linked agammaglobulinaemia (XLA) and 34 of common variable immunodeficiency (CVID) are reviewed. Although immunoglobulin substitution largely abolished life-threatening respiratory tract infections, considerable infectious and non-infectious morbidity was still encountered in these patients. Almost all patients suffered from chronic or recurrent upper and lower airway infections, mainly caused by Haemophilus influenzae and pneumococci. The lower respiratory tract infections led to cumulative damage to the respiratory tract, especially in XLA patients. Also the incidence of infections outside the respiratory tract (giardiasis, Campylobacter jejuni infections) was more common in XLA patients than in CVID patients. Nodular lymphoid hyperplasia was only found in CVID. A variety of other non-infectious complications were seen especially in CVID. Neoplastic complications occurred in nine patients (two cases of thymoma, two colorectal cancer, one gastric carcinoma, two haematological malignancies, two cases of skin cancer). Six patients died (five XLA patients and one CVID patient, from infectious and non-infectious causes).     

Prospective safety study of immunotherapy administered in a cluster schedule.

Cluster immunotherapy is becoming an alternative to conventional IT due to its shorter schedule, but the safety of such schedule is still controversial. At present, only few studies assess the risk of immunotherapy in a prospective manner, in well-controlled patients, using the same extract and intending to evaluate a single schedule. The aim of the present study is to evaluate the safety of a cluster immunotherapy administration regimen. A total of 91 outpatients (41 male and 50 female), with a mean age of 25 years old (range: 16-50) were included. Sixty-one patients were diagnosed mild to moderate asthma and 30 rhinoconjunctivitis. Forty-six of the enrolled patients were sensitised to pollen (Lolium perenne and/or Olea europea), 38 to Dermatophagoides pteronyssinus and 7 to Alternaria alternata. Patients received specific immunotherapy following a five-week cluster schedule. It was considered as a preseasonal treatment, that is, it was accomplished before olive and grass initial pollinating months in this area (March--April). A total 1029 injections were administered during the induction phase. Adverse reactions were assessed and classified according to the EAACI criteria. The average number of visits to maximum dose was 6 (range 2-10), and 70 patients (77%) reached the maximum between 5-7 visits. In each of the visits an average of 2 (range 1-3) injections were administered. Eighty-one of the 91 initially enrolled patients (89%) completed the cluster schedule. The total number of reactions were 47 (24 local and 23 systemic). No fatal reactions were observed. Since the total number of administered injections was 1029, the relative frequency of adverse reactions was 4.6% (2.3% local and 2.2% systemic). The percentage of patients affected by systemic reaction was 18% and by local reaction 14%. No relationship can be shown between adverse reactions and gender or disease. However, a clear relationship with the composition of immunotherapy has been shown, with a lower risk of adverse reactions associated with the extract of D. pteronyssinus. The shorter period required to achieve the maintenance dose, with a similar frequency of adverse events, leads to the conclusion that the proposed administration regimen can be an alternative to conventional schedule to increase patient compliance.     

Safety of pyridostigmine in hypertensive patients receiving beta blockers.

In the last decade, pyridostigmine, a quaternary carbamate that reversibly inhibits the enzyme acetylcholinesterase, was proposed for pretreatment of nerve gas (organophosphate) poisoning. The objective of this study was to assess the cardiovascular effects of pyridostigmine in patients treated with beta blockers. Eight hypertensive patients receiving regular treatment with beta blockers were randomized in a double-blind crossover study to receive pyridostigmine (30 mg 3 times daily) or placebo for 2 days. Heart rate and blood pressure in the supine and standing positions were recorded every 2 hours during the day, and 24-hour Holter monitoring was performed. In addition, a symptom-limited exercise test was performed, and plasma catecholamine levels were determined at rest and at peak exercise. Pyridostigmine, as compared with placebo, did not induce any significant effect on heart rate, plasma catecholamine levels or resting blood pressure. Both systolic and diastolic blood pressures increased in accordance with exercise intensity (p less than 0.01), although a significantly lower diastolic blood pressure was observed when pyridostigmine was used (average decrease 5 mm Hg compared with placebo; p less than 0.01). No clinical adverse reactions were observed, confirming the relative safety of the combination of low-dose pyridostigmine with beta-adrenergic blocking agents.     

Tolerance and effects on skin reactivity to latex of sublingual rush immunotherapy with a latex extract.

BACKGROUND: Specific immunotherapy could be a therapeutic tool for the increasing problem of sensitisation to Natural Rubber Latex (NRL). OBJECTIVE: To investigate the tolerability of SLIT for Latex and its effects on skin reactivity. METHODS: Twenty-six patients (mean age 35.5 years) with an average history of 7.5 years of cutaneous symptoms plus respiratory symptoms (23/26) due to NRL were studied. All underwent rush sublingual therapy (4 days) with a standardized NRL extract followed by a 9-week maintenance treatment. Local and systemic adverse reactions were monitored throughout the treatment. Skin reactivity to NRL extract was evaluated before, during and at the end of the treatment by latex glove-use test, rubbing test and skin prick test. RESULTS: All patients reached the maintenance dose. Out of 1044 administered doses, 257 (24.6%) produced adverse reactions from which 21.4% were local. Only 10.1% of cases required treatment, mainly with antihistamines alone (5.8%), with 2-agonists alone (0.8%) or associated to antihistamines and/or corticosteroids (2.7%). One patient was precautionary treated twice with adrenaline but completed the treatment without further problems. The glove-use test improved significantly after 5 days and 10 weeks of treatment (p = 0.003, p = 0.0004 respectively), whereas the rubbing test improved significantly only after 10 weeks of treatment. Doctor's assessments confirmed the results obtained with the glove-use test (p = 0.003 after 5 days, and p = 0.004 after 10 weeks) but not those obtained with the rubbing test. No change was detected for SPTs. CONCLUSION: SLIT for NRL allergy is able to modify skin reactivity to NRL in days as assessed with methods reproducing HCWs normal exposure to the allergen. Tolerance of SLIT is better than tolerance reported for injective therapy with NRL, but the build up phase should be administered under medical surveillance until sufficient experience has been accumulated. The long-term effect of the treatment deserves further investigation.     

Safety of specific immunotherapy using a four-hour ultra-rush induction scheme in bee and wasp allergy.

BACKGROUND: Ultra-rush induction of immunotherapy with Hymenoptera venom is a reliable and efficacious alternative to the rush induction protocol, though not widely used in European countries yet. Its safety, however, has been intensively discussed over the last few years. The aim of this retrospective case study was to examine the rate of allergic side-effects during our four-hour ultra-rush hymenoptera venom induction regimen. We evaluated risk factors for observed side-effects such as age, gender, severity of previous insect sting reactions according to the H.L. Mueller classification, concentration of venom inducing positive skin tests, level of specific IgE, serum tryptase concentration, and hymenoptera venom used for treatment. METHODS: 67 outpatients with Hymenoptera venom allergy received 80 courses of ultra-rush immunotherapy. Diagnosis and selection of patients for venom immunotherapy were carried out according to the European Academy of Allergology and Clinical Immunology. We applied a four-hour regimen, and local or systemic reactions were documented. RESULTS: In 78 courses (97.5%) the maintenance dose of 111.1 microg was reached within 4 hours and it was tolerated in 82.5% without any hypersensitivity reaction. Allergic side-effects were observed in only 17.5% (n=14): four severe local reactions (5%), eight grade I (10%) and two grade II (2.5%) systemic reactions. There was no significant difference in the number of systemic reactions comparing patients receiving wasp or honeybee venom extract. The number of systemic reactions was neither higher in patients with a severe prior insect sting reaction (grade III or IV) nor dependent on age, gender, skin test reaction, level of specific IgE or tryptase. Epinephrine as rescue medication was never needed. Interestingly, patients with a severe prior wasp sting reaction showed a significantly lower incidence of allergic side-effects during ultra-rush immunotheraphy with wasp venom extract as compared to grade III or IV honeybee venom allergic patients. CONCLUSION: Our ultra-rush immunotherapy induction regimen shows a low incidence of systemic reactions. It proved to be safe and convenient for the patient, as it could be applied in a four-hour outpatient regimen.     

Safety of immunotherapy in patients with rhinitis,asthma or atopic dermatitis using an ultra-rush buildup. A retrospective study

BackgroundAllergen-specific immunotherapy is a proven, highly effective treatment for IgE–mediated diseases. However, ultra-rush immunotherapy is prescribed infrequently because of the perception that accelerated immunotherapy buildup leads to a higher rate of systemic reactions.ObjectiveTo evaluate the frequency of adverse reactions in patients with IgE–mediated diseases receiving house dust mite (HDM) ultra-rush immunotherapy.MethodsA retrospective, observational study was conducted for patients with IgE–mediated diseases receiving allergen-specific immunotherapy. Subcutaneous immunotherapy with depigmented polymerized mites extract was administered in two refracted doses of 0.2 and 0.3 ml at first injection, and in single 0.5 ml doses in subsequent monthly injections. A 30 min observation time was required after each injection. Systemic reactions were graded using the World Allergy Organisation grading system.Results575 patients were included. The age range was 1–83 years. Most patients had respiratory diseases (544) and 101 patients had atopic dermatitis. A total of 27 patients (4.6%) experienced 139 reactions (reactions/injections: 1.9%); 22 patients (3.8%) experienced 134 local reactions (local reactions/injections: 1.8%). Eight patients (1.3%) experienced eight systemic reactions (systemic reactions/injections: 0.1%). Five systemic reactions were grade 2 and three grade 1. Two systemic reactions were reported during buildup. There were no fatalities.ConclusionTaking into account the possible bias for the retrospective design of this study we observed that immunotherapy for patients with IgE–mediated diseases using a depigmented polymerized mites extract, with an ultra-rush buildup, has similar frequency of systemic reactions than that seen in slower buildup immunotherapy in other studies. Accelerated buildup could improve patients’ adherence and reduce dropout rates.     

Safety Profile of Thiopurines in Crohn Disease: Analysis of 893 Patient-Years Follow-Up in a Southern China Cohort

Thiopurines have been associated with both clinical improvement and mucosal healing in treating Crohn disease (CD). Unfortunately, the high rate of adverse events (AEs) leading to drug withdrawal represents a major limitation in the use of these drugs.To evaluate the safety of thiopurines in patients with CD. To identify predictive factors associated with the development of thiopurine-induced AEs and withdrawal.This longitudinal cohort study examined patients from a university-based IBD referral center. Time-to-event analysis was performed with the Kaplan–Meier curve. Cox regression analysis was performed to identify potential predictive factors of AEs.Two hundred sixty-seven CD patients on thiopurines were included. A total of 143 AEs occurred at a median of 7.4 months (interquartile range, 3.7–15.3 months) after starting treatment. The cumulative incidence of AEs was 26%, with an annual risk of 4.3% per patient-year of treatment. The most frequent was leucopenia (41/267, 15.36%), followed by infections (29/267, 10.86%). Independent factors predictive of leucopenia were lower baseline hemoglobin (hazard ratio (HR), 0.34; 95% confidence interval (CI) 0.18–0.67) and the concomitant use of 5-aminosalicylic acid (HR, 3.05; 95% CI 1.44–8.76). Of the 28.44% (76/267) CD patients discontinued therapy, 14.61% due to AEs. A lower body mass index, the presence of extraintestinal manifestation, and the incidence of leucopenia independently predicted thiopurine withdrawal. In total, 37.5% of these patients restarted thiopurines and 52.3% of them had AEs again.About a quarter of patients on thiopurine therapy had AEs during follow-up and 1 of 7 patients had to discontinue thiopurines due to AEs.     

Detection of circulating donor white blood cells in patients receiving multiple transfusions.

Significant morbidities are associated with the routine administration of blood products. Although the exact etiology of these complications may be unknown, many are thought to arise from the incidental cotransfusion of "donor" lymphocytes. We have developed an assay to detect small numbers of male white blood cells (WBCs) circulating in female patients who have received multiple blood transfusions using the polymerase chain reaction (PCR). Twenty female patients undergoing major surgical procedures were studied and received an average of 9.3 U of packed red blood cells (4.8 U from male donors) and 11.7 U of platelets (6.1 U from male donors). DNA was extracted from whole blood or peripheral blood buffy coats posttransfusion and PCR performed using oligonucleotides designed to amplify a segment within the repetitive Y-chromosome DYZ1 locus. Posttransfusion, 15 of 20 women showed evidence of circulating male WBCs for an average of 2.0 days (range, 1 to 6). We conclude that (1) DYZ1 PCR analysis is a useful approach for the detection of small numbers of circulating transfused male WBCs in female patients; and (2) circulating donor WBCs persist for a mean of 2.0 days in the majority of women receiving multiple transfusions. Future application of this technique may detect persisting or proliferating WBCs and lead to an improved understanding of common transfusion-related morbidities.     

Blood stem cell collection using chemotherapy with or without systematic G-CSF: experience in 52 patients with multiple myeloma.

Harvesting of peripheral blood stem cells (PBSCs) following chemotherapy and G-CSF administration is currently performed for hematological therapies. However, a procedure based on the use of a large quantity of G-CSF is relatively costly. Therefore, we retrospectively compared the effects of two PBSC mobilization procedures in a population with recently diagnosed multiple myeloma. The first procedure consisted of chemotherapy and systematic G-CSF administration (group 1: 24 patients). The second consisted of chemotherapy alone, G-CSF having been administered only in the case of failure of PBSC mobilization or delayed white blood cell (WBC) recovery (group 2: 28 patients). Leukapheresis was performed when WBC recovery reached 1 x 10(9)/l if the peripheral blood CD34+ cell count was over 10/microl. Leukapheresis was maintained until a total of 2.5 x 10(6) CD34+ cells/kg was harvested. A significant difference was observed between the two groups only in regard to the median period of WBC recovery (delayed for group 2) and the number of CD34+ cells/kg collected on the first leukapheresis (higher for group 1) but not to the proportion of patients with failure of PBSC collection. Ten group 2 patients, who had insufficient CD34+ cells after WBC recovery or delayed WBC recovery, received G-CSF which resulted in sufficient PBSC harvesting in nine. To obtain a sufficient CD34+ cell level, the patients without systematic G-CSF administration had more leukaphereses (2.1 vs 1.5) but the mean consumption of G-CSF per patient was eight times less than in the other group. Nonsystematic use of G-CSF before WBC recovery or preferentially its introduction just after, could be an interesting economical alternative in PBSC mobilization but should be assessed by a prospective controlled study of cost/efficacy.     

Systemic reaction rates to field stings among imported fire ant-sensitive patients receiving >3 years of immunotherapy versus <3 years of immunotherapy.

As imported fire ants (IFAs) expand their range, hypersensitivity reactions to their stings are becoming a significant cause of morbidity and mortality in the United States. Currently, IFAs whole body extract (WBE) immunotherapy is the mainstay of treatment for IFA hypersensitivity but the optimal duration of treatment is unknown. A questionnaire was administered to patients diagnosed with IFA venom hypersensitivity based on history and the presence of IFA venom-specific IgE who had been offered immunotherapy. The patients were grouped into those who received > or =3 years of immunotherapy and those who received <3 years of immunotherapy. Forty of the 272 patients initially identified were successfully contacted (14%) with 6 patients being excluded. Of these patients, 19 reported having received <3 years of IFA immunotherapy (reduced course) and 15 stated they had been given >3 years of immunotherapy (complete course). Subsequent field stings were reported by 18 (95%) of the reduced course groups and 14 (93%) of the complete course group with 1 person from each group (6 and 7%, respectively) experiencing a systemic reaction. There were no significant differences between the two groups in the number of patients with subsequent field stings or systemic reactions after subsequent IFA stings. Less than 3 years of IFA immunotherapy may offer long-term protection against IFA hypersensitivity reactions although additional studies with more subjects and controls are necessary before definitive conclusions may be made.     

Phase I study of maytansine using a 3-day schedule.

Maytansine, a new ansa macrolide antitumor antibiotic, was administered to 60 patients as part of a phase I study. The doses given ranged from 0.01 (starting level) to 0.9 mg/m2 for 3 days. The toxic effects encountered consisted principally of nausea, vomiting, diarrhea, and occasionally, stomatitis and alopecia. Superficial phlebitis was also encountered and occurred when the drug was diluted in a volume of less than 250 ml. Myelosuppression occurred infrequently; it was almost regularly associated with abnormal liver function tests. Antitumor activity was detected in one patient each with melanoma, breast carcinoma; and head and neck clear cell carcinoma. Further studies are indicated with this compound since it has shown evidence of activity with little or no myelosuppression.     

Safety of formoterol Turbuhaler at cumulative dose of 90 microg in patients with acute bronchial obstruction.

This study compared the safety of formoterol (Oxis Turbuhaler; 90 microg delivered dose; 120 microg metered dose) with terbutaline (Bricanyl Turbuhaler; 10 mg), in patients with acute bronchoconstriction. Forty-eight patients (31 females) with a mean age of 45 yrs, were randomized into two parallel groups (double-blind design). Mean baseline forced expiratory volume in one second (FEV1) was 0.98 L (33% of predicted normal). Study drugs were administered on six occasions during 3 h (formoterol 4.5 microg or terbutaline 0.5 mg x inhalation(-1), 20 inhalations). Patients received intravenous prednisolone after 1.5 h and oxygen during the first 3 h. Pulse rate, serum potassium, 12-lead electrocardiogram (ECG), Holter ECG, arterial blood gases and FEV1 were assessed during 12 h after the first dose. Four patients (one formoterol, three terbutaline) discontinued. The 12-h mean values of serum potassium decreased from 4.02 to 3.89 mmol x L(-1) for formoterol and from 4.22 to 3.76 mmol x L(-1) for terbutaline. Mean 12-h pulse rate was significantly (p<0.01) higher in the terbutaline group (101.7 beats per minute (bpm)) than in the formoterol group (93.5 bpm). No individual patient value was considered clinically important or alarming. FEV1 improved in both groups but with no statistically significant difference between treatments. Oxis Turbuhaler (90 microg) was at least as safe and well tolerated as terbutaline (10 mg) [corrected] in patients with acute bronchoconstriction.     

Safety of allergen immunotherapy: a review of premedication and dose adjustment

From the first allergen immunotherapy proposed in the early 1900s to the present day, numerous studies have proven the efficacy of allergen immunotherapy for the treatment of allergic rhinitis, allergic conjunctivitis, allergic asthma and stinging insect hypersensitivity. The major risk, however small, with allergen immunotherapy is anaphylaxis. There has been considerable interest and debate regarding risk factors for immunotherapy reactions (local and systemic) and interventions to reduce the occurrence of these reactions. One of these interventions that is especially debated regards dose adjustment for various reasons, but in particular for local reactions. In this review, we discuss the safety of immunotherapy and provide a comprehensive review of the literature regarding immunotherapy schedules and doses.     

Safety of tacrolimus in patients with rheumatoid arthritis: long-term experience

OBJECTIVE: To evaluate the long-term safety of tacrolimus 3 mg/day in patients with rheumatoid arthritis (RA). METHODS: Patients with active RA who had discontinued all DMARDs for at least 2 weeks and had at least five tender/painful joints and three swollen joints, and required DMARD treatment in the opinion of the investigator, were enrolled into this open-label long-term safety trial. In addition, patients who had completed at least 3 months of treatment with tacrolimus 2 mg/day, tacrolimus 3 mg/day or placebo in a Phase III double-blind efficacy trial were allowed to roll over into this study. This latter group of patients did not have to fulfil any joint count requirements prior to entry into the long-term safety study, provided that no more than 14 days had elapsed between the end of their participation in the double-blind study and screening for the long-term safety study. All patients enrolled received tacrolimus 3 mg/day in addition to their current regimen of NSAIDs and corticosteroids. RESULTS: 896 patients received at least one dose of tacrolimus 3 mg. The median duration of treatment was 359 days. 145 patients (16.2%) withdrew from the study for adverse events possibly or probably related to tacrolimus, 33 patients (3.7%) withdrew from the study for adverse events unrelated to tacrolimus and 112 (12.5%) withdrew for lack of efficacy. No adverse event with an incidence >0.7% appeared for the first time after the first 3 months of treatment with 3 mg tacrolimus. 529 patients (59%) experienced an adverse event that was possibly or probably related to tacrolimus; the most common were diarrhoea (14.6%), nausea (10.3%), tremor (9.0%), headache (8.7%), abdominal pain (7.9%), dyspepsia (7.6%), increased creatinine (6.8%) and hypertension (5.4%). Twenty-four patients (2.7%) experienced serious adverse events possibly or probably related to study drug; the most common were pneumonia (0.6%), hyperglycaemia (0.3%), gastroenteritis (0.2%), pancreatitis (0.2%) and diabetes mellitus (0.2%). The mean creatinine level increased from 67+/-19 micromol/l (0.76+/-0.22 mg/dl) at baseline to 75+/-26 micromol/l (0.85+/-0.30 mg/dl) (P<0.0001) at end of treatment. 351 (40.3%) of the 872 patients for whom creatinine levels were available at both baseline and during treatment had > or =30% increase from baseline in serum creatinine during the study, either related or unrelated to tacrolimus, with 73 patients (8.4%) having creatinine levels exceeding the normal range. At end of treatment, 177 patients (20.3%) had a > or =30% increase from baseline in creatinine. Serum creatinine remained within the normal range throughout the trial in approximately 90% of patients. At the end of treatment, the ACR20, ACR50 and ACR70 response rates were 38.4%, 18.6% and 9.0% respectively. Over 26% of patients had at least a 70% improvement in both swollen and painful/tender joints. CONCLUSION: This study demonstrates that tacrolimus was safe and well-tolerated and provided clinical benefit over a period of at least 12 months.     

Effect of cumulative bortezomib dose on survival in multiple myeloma patients receiving bortezomib‐melphalan‐prednisone in the phase III VISTA study

This analysis, using data from the bortezomib‐melphalan‐prednisone (VMP) arm of the Phase III VISTA study, investigated whether increased cumulative bortezomib dose could improve overall survival (OS) in transplant‐ineligible patients with previously untreated multiple myeloma. Median cumulative bortezomib dose received by the 340 patients was 39 mg/m²; this was selected as the cut‐off for defining the dose groups to be compared for OS. Patient characteristics were well balanced between dose groups except for age. OS was significantly longer in the higher (≥39 mg/m²) versus lower (<39 mg/m²) cumulative bortezomib dose group (median 66.3 vs. 46.2 months; hazard ratio (HR) 0.533, P < 0.0001; age‐adjusted HR 0.561, P = 0.0002). To overcome confounding effects of early discontinuations/deaths, which were more common in the lower cumulative dose group (27 vs. 4% of patients discontinued due to adverse events (AEs) in the lower and higher cumulative dose groups, respectively), a landmark analysis was conducted at 180 days, eliminating patients who died or discontinued before this time from the analysis. OS from this landmark remained significantly longer in the higher dose group (median 60.4 vs. 50.3 months; HR 0.709, P = 0.0372). Thus, higher cumulative bortezomib dose, reflecting prolonged treatment duration and/or dose intensity, appears associated with improved OS. Approaches to achieve higher cumulative doses could include subcutaneous bortezomib administration, dose/schedule modifications, continuing therapy in responding patients, and proactive AE management. Am. J. Hematol. 90:314–319, 2015. © 2015 Wiley Periodicals, Inc.     

Recombinant interferon-alpha-2b treatment of hairy-cell leukaemia: experience with a low-dose schedule

50 patients with hairy cell leukaemia (HCL) were treated with recombinant interferon (IFN) alpha-2b 2.0 x 10(6) IU/m2 subcutaneously three times weekly to evaluate the efficacy of low-dose IFN therapy in inducing and maintaining remission of the disease. At the time of this report 48 patients, of whom 22 were splenectomized, had been treated for at least 3 months and were considered evaluable for response. The median observation time on IFN-alpha-2b was 11 months (range 3 to 20). 4 cases with atypical disease (spongy lymphoid myelofibrosis) were also included. All patients responded to IFN. After 3 months 11/48 patients (23%) had achieved a partial remission (PR) with normalization of peripheral blood values. After 6 months 27/43 patients (63%) had achieved a favourable response; complete remission (CR) was recorded in 4 and PR in 23 patients. The proportion of patients with favourable responses (CR + PR) increased with the duration of therapy and after 12 months of therapy 23/28 (82%) patients showed CR or PR, 9 patients (32%) being in CR. Splenectomized patients disclosed a trend towards a more rapid response. It is concluded that IFN-alpha-2b is a highly effective first-line therapy for HCL.     

Fungal peritonitis in patients receiving peritoneal dialysis: experience with 11 patients and review of the literature

Despite progress in decreasing the incidence of and improving the therapy for bacterial peritonitis in patients receiving peritoneal dialysis, fungal peritonitis has emerged as a relatively common infection. Hospitalization, recent prior episodes of peritonitis, and antibacterial therapy appear to predispose patients to this infection. Clinically, fungal peritonitis cannot be differentiated from bacterial peritonitis except by gram stain and culture of the dialysate. The most commonly made serious error is the failure to initiate appropriate therapy quickly enough on the basis of these diagnostic parameters. For patients who no longer require dialysis, those for whom a change to hemodialysis is preferred, and those with concomitant life-threatening illness, the recommended therapy for fungal peritonitis is removal of the dialysis catheter and the institution of therapy with systemic antifungal agents. For patients who are hemodynamically and metabolically stable and for whom continued peritoneal dialysis is desirable, a trial of antifungal chemotherapy before removal of the catheter may be indicated.