Relapsing culture-negative peritonitis in peritoneal dialysis patients exposed to icodextrin solution

Icodextrin is a new peritoneal dialysis fluid, with maltose polymers providing the osmotic drive, that may extend time on peritoneal dialysis in situations in which use of conventional glucose-based peritoneal dialysis fluid (Dianeal) has led to loss of ultrafiltration. Although cutaneous reactions have been reported, we report a new phenomenon of aseptic peritonitis that has arisen in our unit associated with icodextrin use.

Icodextrin was first introduced in our unit in 1997 and was used extensively beginning in late 1999. From a combination of an observational study of 141 patients in our unit in whom icodextrin was used over 3.5 years and our unit 2000 and 2001 peritonitis audits, we identified an increase in the incidence of culture-negative peritonitis (CNP).

The rate in 2000 of 12.3% rose to 17% in 2001, but this increase was seen only in patients on icodextrin (Percentage changes 2000 audit > 2001 audit: icodextrin patients, 14%--31% increase; Dianeal alone, 12%--10% increase; P < 0.05). Six patients were affected in the period 2000 to 2001 out of a total of 141 patients exposed to icodextrin (4.3%). Two index cases of relapsing CNP responded after withdrawal of the icodextrin. We then adopted a protocol of cessation and rechallenge with icodextrin when dealing with CNP, which successfully confirmed the phenomenon and led to resolution of relapsing CNP after icodextrin withdrawal. All these patients had been on icodextrin for some time, and none had had an immediate reaction or any skin reaction. Eosinophils were reported in the peritoneal effluent from two patients. All patients continued Dianeal without further CNP episodes.

Icodextrin use carries the risk of CNP, and we suggest a cessation and rechallenge protocol in all patients on icodextrin who have CNP.