Management of Funguria in CKD Stage V
For a CKD stage V patient with fungi in urine, antifungal prophylaxis is NOT recommended—instead, eliminate predisposing factors (remove catheters) and only treat if the patient is neutropenic, undergoing urologic procedures, or has symptomatic infection. 1
Critical First Step: Determine if Treatment is Needed
The Infectious Diseases Society of America strongly recommends against routine antifungal treatment for asymptomatic candiduria unless specific high-risk criteria are met 1, 2:
High-risk groups requiring treatment:
For asymptomatic candiduria in CKD stage V without these risk factors: No antifungal treatment is indicated 1, 2
Essential Non-Pharmacologic Management
Remove indwelling bladder catheters immediately if present—this is the single most important intervention and strongly recommended by the Infectious Diseases Society of America 1, 2. Elimination of predisposing factors alone often resolves candiduria without antifungal therapy 1.
If Treatment is Required: Species-Specific Approach
For Fluconazole-Susceptible Species (C. albicans)
Fluconazole 200 mg orally daily for 2 weeks is the recommended treatment for cystitis 1, 2. However, in CKD stage V, critical dosing adjustments are necessary:
- Fluconazole requires 50% dose reduction in severe renal impairment, as renal clearance decreases proportionally with creatinine clearance and half-life extends to >100 hours 3
- For dialysis patients, give fluconazole after each dialysis session 3
For Fluconazole-Resistant Species (C. glabrata, C. krusei)
Amphotericin B deoxycholate 0.3-0.6 mg/kg daily for 1-7 days is recommended by the Infectious Diseases Society of America 1, 4, 2.
Critical caveat for CKD stage V: Amphotericin B deoxycholate has the highest nephrotoxicity potential among all antifungals 5, 6. In patients with pre-existing severe renal dysfunction:
- Liposomal amphotericin B (5 mg/kg daily) is the preferred alternative, offering greatly improved tolerability with preserved efficacy 7
- No dose adjustment needed for renal impairment with either formulation 5
- Alternative: Flucytosine 25 mg/kg four times daily for 7-10 days (for C. glabrata only, not active against C. krusei) 1, 2
For Pyelonephritis
Higher fluconazole doses (200-400 mg daily for 2 weeks) are recommended for fluconazole-susceptible species 1, 2, with appropriate renal dose adjustments 3.
Prophylaxis for Urologic Procedures
If your patient requires urologic manipulation, prophylaxis IS indicated:
- Fluconazole 400 mg (6 mg/kg) daily OR amphotericin B deoxycholate 0.3-0.6 mg/kg daily for several days before and after the procedure 1, 2
- Adjust fluconazole dose for dialysis schedule 3
Special Consideration: If Candidemia Develops
If blood cultures become positive (candidemia from urinary source), immediately initiate an echinocandin (caspofungin, micafungin, or anidulafungin) regardless of renal function 8. Echinocandins require no dose adjustment in renal failure and are first-line for candidemia 8.
Important pitfall: Echinocandins do NOT achieve adequate urine concentrations and should never be used for isolated cystitis or pyelonephritis without candidemia 8.
Monitoring Requirements
- Obtain fungal species identification and susceptibility testing, particularly for C. glabrata which has inherently reduced fluconazole susceptibility 8, 9
- Follow-up urine cultures to document clearance 4, 2
- Monitor for amphotericin B nephrotoxicity (though baseline renal function already severely compromised) 5, 6