Skip to main content

Resolution of severe eosinophilic peritonitis in a patient on continuous ambulatory peritoneal dialysis by changing from Dianeal peritoneal dialysis solution to Stay-Safe Balance solution: a case report

Abstract

Background

Eosinophilic peritonitis is a well-known complication at the initiation of peritoneal dialysis. It is often due to an allergic reaction to peritoneal dialysis solution or sometimes to the peritoneal dialysis catheter itself. Most cases are self-limiting with expected spontaneous resolution within a few weeks. Treatment is necessary for severe or persistent cases. However, the optimal treatment has not yet been defined. There have been only a few case reports on the use of anti-histamines and/or steroids for the treatment of eosinophilic peritonitis. We reported a case of severe eosinophilic peritonitis successfully treated by switching the brand of peritoneal dialysis fluid (same glucose concentration). To the best of our knowledge, this is the first reported case employing such a treatment strategy.

Case presentation

An eighty-two-year-old man with end-stage renal failure was started on continuous ambulatory peritoneal dialysis with Dianeal® (Baxter) peritoneal dialysis solution. He developed eosinophilic peritonitis 19 days after initiation of peritoneal dialysis. Infectious causes were ruled out by bacterial, fungal and tuberculosis smears and cultures. In view of the persistent and severe symptoms, we intervened by switching from Dianeal® (Baxter) peritoneal dialysis solution to Stay-Safe Balance® (Fresenius) solution with the same glucose concentration. His eosinophilic peritonitis resolved 5 days after switching the peritoneal dialysis solution.

Conclusion

In severe or persistent cases of eosinophilic peritonitis requiring treatment, other than the use of steroids and anti-histamines, switching to a different brand of peritoneal dialysis solution can be considered.

Peer Review reports

Background

Eosinophilic peritonitis is defined as an absolute eosinophil count greater than 100/mm3 in the peritoneal dialysis fluid (PDF) effluent or when eosinophils constitute more than 10% of the total white blood cell (WBC) count [1]. It tends to occur early (within 3 months) after initiating peritoneal dialysis (PD) and is attributed to hypersensitivity reactions to PD materials, including PDF or the PD catheter itself [2]. It can also be induced by medications [3, 4]. Occasionally, eosinophilic peritonitis can occur with fungal or parasitic infections, or it can occur during the treatment phase of bacterial peritonitis. Careful clinical history and laboratory tests including culture of the PDF effluent are needed to distinguish infectious from non-infectious causes.

Case presentation

An eighty-two-year-old man with end-stage renal failure due to polycystic kidney disease was newly started on PD. He was put on intermittent PD two weeks after PD catheter insertion and was later started on continuous ambulatory peritoneal dialysis at one month. His PD regimen consisted of 1.5% 2L Dianeal® (Baxter) PDF three bags exchanged per day. He was admitted to the hospital 19 days later for turbid PDF effluent. The total PDF effluent WBC count was 5643/mm3, with 29% neutrophils, 2% lymphocytes, 13% monocytes and 56% eosinophils. He did not have fever or abdominal pain. Intraperitoneal vancomycin and amikacin were started empirically upon admission. Antibiotics were chosen in view of the patient’s known allergies to penicillin, erythromycin and levofloxacin. He had also been taking amlodipine, lisinopril, terazosin, frusemide, ferrous sulphate, pantoprazole, vitamin B complex, vitamin C and methoxy polyethylene glycol epoetin beta subcutaneous injection. There had been no change in medications since PD catheter insertion. The bacterial and fungal cultures of the PDF effluent and a polymerase chain reaction test for Mycobacterium tuberculosis complex DNA were all negative. However, the PDF effluent was persistently turbid with a marked decrease in ultrafiltration. Eosinophilic peritonitis due to an allergic reaction was suspected. All intraperitoneal antibiotics were stopped, with oral chlorpheniramine prescribed on day 11 after admission. The PDF effluent remained turbid, with a total WBC count ranging from 5000-6000/mm3. We switched the 1.5% 2L Dianeal® (Baxter) PDF to 1.5% 2L Stay Safe Balance® (Fresenius) PDF on day 14 after admission. There was significant improvement in the turbidity of the PDF effluent the next day (total WBC count 1320/mm3, eosinophils 72%), and it eventually cleared up on day 19 (total WBC count 40/mm3). There was no recurrence of turbid PDF effluent until the latest follow-up at one month after discharge.

Discussion and Conclusion

Eosinophilic peritonitis due to an allergic reaction is a well-known complication of PD. It ranges from asymptomatic mild turbidity of the PDF effluent, which is sometimes only demonstrated after nocturnal dwelling, to overtly turbid PDF effluent with symptoms. Mild eosinophilic peritonitis is most often self-limiting and resolves spontaneously, while severe cases may persist and require treatment. There is a paucity of data for the optimal treatment of clinically significant eosinophilic peritonitis. There have been a few case reports on the successful treatment of eosinophilic peritonitis with steroids [5,6,7], anti-histamines [7, 8] and montelukast [9].

We reported a case of severe eosinophilic peritonitis successfully treated by switching the brand of PDF. To the best of our knowledge, this is the first reported case employing such a treatment strategy. There have been reports on allergic reactions to icodextrin solution used in PD, with resolution after switching to standard glucose-based PDF [10, 11]. Some of the earlier cases were probably due to the contamination of some icodextrin batches by peptidoglycans during manufacture [12]. However, there has been no previous report on treatment by switching from one glucose-based PDF to another.

The Stay-Safe Balance PDF consists of two-compartment solution bags, which are allowed to mix at the time of use. It has the advantage of providing a low glucose degradation product solution at neutral pH when compared to the conventional bag system employed by other PDFs. However, there is no consistent evidence on whether the more physiological solution can actually translate into clinical benefits [13, 14]. It is unclear in our case whether the resolution of eosinophilic peritonitis was due to the above-mentioned properties of the Stay-Safe Balance® (Fresenius) PDF or whether it was due to the difference in their excipients or materials used for the plastic container bags. According to the manufacturers, all components of the packaging for Stay-Safe Balance® (Fresenius) solution are made of polyvinyl chloride (PVC)-free Biofine®, whereas Dianeal® (Baxter) solutions are packed in bags made of PVC. We avoided the use of steroids, which are the most reported agents used for the treatment of eosinophilic peritonitis, so that the side effects of steroids could be avoided in this elderly patient. Switching of the brand of PDF represents a reasonable choice for the treatment of severe eosinophilic peritonitis with few potential side effects.

We did not perform any rechallenge test for this patient, as the inflammatory response was severe, and the temporal sequence was compatible with the allergic response to the initial choice of PDF. The patient also had history of allergy to multiple groups of antibiotics. He might have an underlying increased tendency to hypersensitivity reaction. Although the causal relationship between Dianeal® (Baxter) PDF and eosinophilic peritonitis could not be directly proven in this case, their apparent associations merit consideration.

Eosinophilic peritonitis can be caused by an allergic reaction to PDF, drugs or, in some cases, infectious processes, such as fungal peritonitis. After ruling out infectious peritonitis, most cases can be managed conservatively with expected spontaneous resolution. In severe or persistent cases, other than the use of steroids and anti-histamines, switching to a different brand of PDF can be considered.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

PD:

Peritoneal Dialysis

PDF:

Peritoneal Dialysis Fluid

PVC:

Polyvinyl Chloride

WBC:

White Blood Cell

References

  1. Oh SY, Kim H, Kang JM, et al. Eosinophilic peritonitis in a patient with continuous ambulatory peritoneal dialysis (CAPD). Korean J Intern Med. 2004;19(2):121–3.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Chan MK, Chow L, Lam SS, et al. Peritoneal eosinophilia in patients on continuous ambulatory peritoneal dialysis: a prospective study. Am J Kidney Dis. 1988;11:180–3.

    CAS  Article  PubMed  Google Scholar 

  3. Minato S, Miyazawa H, Kitano T, et al. Eosinophilic peritonitis induced by sucroferric oxyhydroxide. Perit Dial Int. 2020;40(4):419–21.

    Article  PubMed  Google Scholar 

  4. Wang Z, Li Z, Luo S, et al. Cefoperazone and sulbactam-related eosinophilic peritonitis: a case report and literature review. J Int Med Res. 2021;49(6):030006052110253.

    Article  Google Scholar 

  5. Xu Y, Gao C, Xu J, Chen N. Successful Treatment of Idiopathic Eosinophilic Peritonitis by Oral Corticosteroid Therapy in a Continuous Ambulatory Peritoneal Dialysis Patient. Case Rep Nephrol Dial. 2015;5(2):130–4.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Albilali AS, Rahim KA, Edrees BM, Alshaya HO. Resolution of eosinophilic peritonitis with oral prednisolone in a child receiving peritoneal dialysis. Perit Dial Int. 2011;31(3):359–60.

    CAS  Article  PubMed  Google Scholar 

  7. Thakur SS, Unikowsky B, Prichard S. Eosinophilic peritonitis in CAPD: treatment with prednisone and diphenhydramine. Perit Dial Int. 1997;17(4):402–3.

    CAS  Article  PubMed  Google Scholar 

  8. Tang S, Lo CY, Lo WK, Chan TM. Resolution of eosinophilic peritonitis with ketotifen. Am J Kidney Dis. 1997;30(3):433–6.

    CAS  Article  PubMed  Google Scholar 

  9. Forbes TA, Lunn AJ. Montelukast: a novel therapeutic option in eosinophilic peritonitis. Pediatr Nephrol. 2014;29(7):1279–82.

    Article  PubMed  Google Scholar 

  10. Tzvi-behr S, Frishberg Y, Ben-shalom E, Rinat C, Becker-cohen R. Eosinophilia in a peritoneal dialysis patient: Answers. Pediatr Nephrol. 2018;33(9):1507–8.

    Article  PubMed  Google Scholar 

  11. MacGinley R, Cooney K, Alexander G, Cohen S, Goldsmith DJA. Relapsing culture-negative peritonitis in peritoneal dialysis patients exposed to icodextrin solution. American J Kidney Dis. 2002;40(5):1030–5.

    CAS  Article  Google Scholar 

  12. Martis L, Patel M, Giertych J, et al. Aseptic peritonitis due to peptidoglycan contamination of pharmacopoeia standard dialysis solution. Lancet. 2005;365(9459):588–94.

    CAS  Article  PubMed  Google Scholar 

  13. Johnson DW, Brown FG, Clarke M, et al. The effects of biocompatible compared with standard peritoneal dialysis solutions on peritonitis microbiology, treatment, and outcomes: the balANZ trial. Perit Dial Int. 2012;32(5):497–506.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  14. Cho Y, Johnson DW, Craig JC, Strippoli GFM, Badve SV, Wiggins KJ. Biocompatible dialysis fluids for peritoneal dialysis. Cochrane Database of Systematic Reviews. 2014;(Issue 3):CD007554.

Download references

Acknowledgements

Not applicable

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

Author information

Affiliations

Authors

Contributions

ZC wrote the first draft of the manuscript. YHH and SSHW reviewed and edited the manuscript and approved the final version of the manuscript.

Corresponding author

Correspondence to Zi Chan.

Ethics declarations

Ethics approval and consent to participate

United Christian Hospital does not require ethical approval for reporting individual cases.

Consent for publication

Written informed consent was obtained from the patient(s) for their anonymised information to be published in this article.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Chan, Z., Hui, Y.H. & Wong, S.S.H. Resolution of severe eosinophilic peritonitis in a patient on continuous ambulatory peritoneal dialysis by changing from Dianeal peritoneal dialysis solution to Stay-Safe Balance solution: a case report. BMC Nephrol 23, 149 (2022). https://doi.org/10.1186/s12882-022-02786-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12882-022-02786-8

Keywords

  • Peritoneal dialysis
  • allergic reaction
  • eosinophilic peritonitis
  • treatment
  • case report