Sterile icodextrin-associated peritonitis may induce hypersensitivity and recurrent peritonitis on re-challenge

Giuseppe Enia, Antonella Mandalari, Giuseppina Ventura, Domenica Pustorino and Vincenzo Panuccio

Divisione Nefrologica, ‘G. Monasterio’ and Centro, di Fisiologia Clinica del CNR, Ospedali Riuniti, Reggio Calabria, Italy. Email: eniag{at}libero.it

Sir,

Peritoneal solutions containing 7.5% icodextrin (ICO) as an osmotic agent are very valuable in the treatment of CAPD patients with defective ultrafiltration or for the long day-time dwell exchange in patients treated with nocturnal automated peritoneal dialysis [1]. However, it is well known that ICO can cause cutaneous allergic reactions [2] and sterile peritonitis [3,4]. Recently, the manufacturer has withdrawn a series of batches of ICO solutions that have been associated with several cases of sterile peritonitis. The cause of this complication is not completely understood and a high content of peptidoglycans in these batches was implicated in the cluster of peritonitis cases.

We recently observed a patient who had a sterile peritonitis during treatment with one of these batches, which recurred several weeks later on re-challenge with new ICO solutions. The patient, a 72-year-old woman suffering from type 2 diabetes, started CAPD in June 2001 with a night dwell of ICO. On 9 May 2002 she developed her first episode of peritonitis. The peritonitis was clinically very mild and the only sign was a cloudy dialysate containing 1000 WBC/mm3. Cultures were negative. She was treated with a course of antibiotics but the count remained slightly high (200–300/mm3) and returned to normal only after stopping the ICO solutions when we were informed that they belonged to one of the batches withdrawn by the manufacturer.

Eight weeks later, to improve the ultrafiltration, we re-introduced ICO with new batches of solution. Immediately after the first ICO exchange the patient had mild abdominal discomfort, with cloudy dialysate and an. increase in WBC count (1100/mm3). The cultures were negative. ICO was stopped and no antibiotic treatment prescribed. The count was 100/mm3 24 h after stopping ICO and 0/mm3 in the days following.

It is possible that the first episode of sterile peritonitis, associated with the use of an ICO batch suspected to have high peptidoglycan levels, might have induced sensitization to ICO which could have been the cause of the new episode on re-challenge. We suggest that doctors treating patients who have been exposed to ICO solutions associated with the recent cluster of chemical peritonitis be aware of the possibility of sensitization to ICO. They must also watch their patients carefully when drugs containing dextran polymers are prescribed (e.g. plasma expanders or iron–dextran complex) because of the theoretical risk of cross-sensitization.

References

  1. Plum J, Gentile S, Verger C et al. Efficacy and safety of a 7.5% icodextrin peritoneal dialysis solution in patients treated with automated peritoneal dialysis. Am J Kidney Dis2002; 39:862–871[ISI][Medline]
  2. Divino Filho JC. Allergic reactions to icodextrin in patients with renal failure. Lancet2000; 355:1364–1365
  3. Pinerolo MC, Porri MT, D'Amico G. Recurrent sterile peritonitis at onset of treatment with icodextrin solution. Perit Dial Int1999; 19:491–492[ISI][Medline]
  4. Fiedler R, Schneider L, Buchmann J, Osten B, Langer T. Does peritoneal dialysis predispose a diabetic patient to icodextrin-induced peritonitis? Nephrol Dial Transplant2002; 17:1708–1709[Free Full Text]




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