P1188ICODEXTRIN-INDUCED CHEMICAL PERITONITIS IN A PATIENT WITH CARDIORENAL SYNDROME
Authors: KAPOTA ATHANASIA , Damianaki Katerina , GIANNOU PANAGIOTA , CHALKIA AGLAIA , MPOUGATSOS GEORGIOS , PETRAS DIMITRIOS 
Published: June 2020

Abstract

Background and Aims
The main cause of morbidity among patients who undergo peritoneal dialysis (PD) remains peritonitis. However there are rare references in published literature about the development of sterile peritonitis related to exposure to PD materials used to overcome the complications from glucose solutions.The objective of the present case report is to enhance clinical suspicion in order to avoid unnecessary antibiotic treatment or catheter removal.

Case description
A 56-year-old male became dialysis dependent from June 2017 due to cardiorenal syndrome type II, after multiple hospitalizations for pulmonary edema within a year. The patient was prescribed icodextrin 7,5% as a single 10-hour nocturnal dwell with dry day period in continuous ambulatory PD .At his scheduled appointment during drainage of the nighttime dialysate, slightly cloudy effluent with a lot of pale yellow substances “sesame” like, were observed without any signs of peritonitis or pathology from the Catheter exit site based on Twardowski classification.The dialysate contained 600 cells/ml. The floating yellow substances after laboratory and light microscopy examination accumulated epithilium cells with rare macrophages were found.Due to these findings,icodextrin was discontinued and empiric antibiotic therapy started including intraperitoneal administration of vancomycin and ceftazidime .After 3 days the floating substances disappeared and the number of cells in dialysate progressively decreased but not within the normal range so empirical antifungal therapy was decided. Daily repeated aerobic, anaerobic and fungal cultures of effluent and blood were negative as well the culture of exit site. ADA (adenosine deaminase test) and β-koch culture were also negative. Computed tomography scan of abdomen and colonoscopy showed no pathology.Due to fluid overload an additional long-term dwell of icodextrin solution was initiated.The re-exposure doubled the number of cells (310 cells/ml) and a second sample was sent for cytological examination which showed plenty of hyperplastic mesothelial cells in piles and isolated, abundant mature lymphocytes, few polymorphonuclear leukocytes as well as several mast cells. Based on these observations peritoneal cavity remained empty for 24 hours. Afterwards a 4-hour exchange of glucose-containing solution of 1,36%, 2,27%, 3,86% and finally of icodextrin was held once daily. The cells were 155, 120, 105 and 450/ml respectively with lymphocytes and mast cells being predominant.Based on these data, it was considered that the exposure to icodextrin produced hypersensitivity and the empiric antibiotic therapy was discontinued.The catheter was removed and sent for culturing which was negative.The biopsy of peritoneal membrane revealed mild fibrous sclerotic lesions, fibrous texture, partially collagenized membrane lacking mesothelial lining and exhibiting sparse chronic nonspecific inflammatory infiltration involving rare neutrophilic leukocytes. Plenty of small blood vessels were observed, with no immunomorphological features including IgG4 staining. These findings were attributed to chemical peritonitis from icodextrin solution ant the patient switched dialysis modality.
Discussion:the use of icodextrin in peritoneal dialysis patients has numerous advantages over glucose-based dialysates including improved ultrafiltration, better fluid control and less hypertension, especially in patients with cardiorenal syndrome. In the face of evident benefits, clinicians should, however, be aware of the potential of icodextrin to induce chemical sterile peritonitis.