Evidence for a role of plasticizers in 'eosinophilic' peritonitis in continuous ambulatory peritoneal dialysis.

Prof. G. Rifle, Hôpital du Bocage, 2, boulevard de-Lattre-de-Tassigny, F-21034 Dijon Cédex (France) Dear Sir, Some patients undergoing continuous ambulatory peritoneal dialysis (CAPD) have developed a culture-negative peritonitis with a high eosinophilic count in the peritoneal dialysis (PD) effluent: so-called ‘eosinophilic peritonitis’. We report a case which strongly suggests the responsibility of plastic containers. A 50-year-old man with angina pectoris and no history of allergy or atopy reached end-stage renal failure because of polycystic kidneys. CAPD was started with 4 exchanges/day of Dianeal 137 solution (Travenol Laboratories, Malton, Ont., Canada) containing 5 mg heparin in each container(Choay Laboratories, Paris, France): two liters of solution with 3 glucose 1,36% w/v and 1 glucose 3.86% w/v. Two days after insertion of a Tenchkoff catheter, the patient developed a cloudy PD effluent without pyrexia, pain or abdominal symptoms. Cell count of dialysate drainage was 615 white cells/μl, with 80% eosinophils and less than 5% red blood cells. Repeated cultures of the PD fluid failed to isolate bacterial or fungal organism, or endotoxin. Before these results reached us, we begun an intraperitoneal antibiotic therapy with cefoperazone (100 mg/l) for 3 days, then trimetoprim (16 mg/l), sulfamethoxazole (80 mg/l) for 4 days. These treatments failed to improve the peritonitis. Neither the withdrawal of antibiotherapy, nor the use of another heparin in the bags (Roche Laboratories, Neuilly-sur-Seine, France), which we also stopped, influenced the cell count. We found no abdominal disease, no tunnel abcess or exit site infection, no air in the peritoneal cavity after insertion of the catheter. Plasma IgE level was 5 U/ml (normal < 10 U/ml) and IgE level in the PD fluid was Choay heparin –––– Roche heparin -Cefoperazone – tm†-smx –– Plastic bags Plastic bags