Cloudy Peritoneal Fluid Attributable to Non-Dihydropyridine Calcium Channel Blocker

Abstract

Editor:A 55-year-old man with hypertension, coronary artery disease, and end-stage renal disease was initiated on automated peritoneal dialysis with 2.5% Dianeal solution [Baxter (India) Private, Haryana, India] 14 days after Tenckhoff catheter placement. On day 0 of initiation, the peritoneal effluent was cloudy. Newspaper print was not visible through the effluent (Figure 1). The patient had no complaints of abdominal pain, fever, loose stools, or vomiting. No fibrin clots were evident, and there were no cells in the effluent. Gram stain, Ziehl-Neelsen stain, and KOH mount of the effluent were negative. Cultures for bacteria and fungi were sterile.The effluent remained cloudy for the next few days, but the patient had no symptoms. There were still no cells on repeat examination, and repeat staining and cultures of the effluent were also negative. The patient's pulse was 78 bpm and his blood pressure was 130/80 mmHg. A clinical examination, including abdominal exam, was unremarkable. There were no clinical features suggestive of acute pancreatitis, solid-organ malignancy, or lymphoma.Effluent triglycerides were measured. The levels were high at 54 mg/dL, 61 mg/dL, and 52 mg/dL on 3 consecutive days. Serum triglycerides were 134 mg/dL. Serum and effluent amylase levels were 12 U/dL and 10 U/dL respectively. In other investigations, serum creatinine was 8.8 mg/dL; blood urea nitrogen, 213 mg/dL; hemoglobin, 9.8 g/dL; and 24-hour urine protein, 230 mg. Contrast-enhanced computed tomography imaging of the abdomen revealed a normal pancreas. Effluent was also negative for malignant cells on repeat examination.The surgeon reported that the catheter insertion had been atraumatic. The patient's medications during this phase of cloudy peritoneal fluid were sevelamer carbonate, injection calcitriol, diltiazem, isosorbide mononitrate, aspirin, and vitamins.Diltiazem, although not a dihydropyridine calcium channel blocker, was stopped. The next day, the effluent became translucent. There were no cells in the effluent. Effluent triglycerides fell to a normal level of 1.0 mg/ dL. After 3 days, the diltiazem was added back to the patient's medications. The effluent became cloudy again, and effluent triglycerides were now 55 mg/dL.Cloudy peritoneal fluid is not always infection (1). An absence of cells excludes infection, intra-or juxta-peritoneal inflammation, allergic reaction to constituents of the dialysis system, air, and pharmaceuticals. Our patient

Peritoneal Dialysis–Associated Peritonitis: Suggestions for Management and Mistakes to Avoid

“…Lymphatic obstruction secondary to lymphoma is another cause of chylous effluent. 56 Acute pancreatitis, 57 certain calcium channel blockers, 58 superior vena cava syndrome, 59 and trauma to the lymphatics following PD catheter insertion are additional causes. 60 …”

Calcium Channel Blocker-Associated Chyloperitoneum in Patients Receiving Peritoneal Dialysis: A Systematic Review

“…The remaining 54 studies were assessed for eligibility by reviewing the full text, 37 of which were subsequently excluded for the following reasons: (1) the study populations did not receive PD ( n = 5); (2) the drug intervention did not include a CCB ( n = 8); (3) chyloperitoneum was not reported as an outcome ( n = 17); (4) the articles were review articles, comments, or conference abstracts ( n = 4); (5) the full text of the article was not available even after its corresponding author was contacted by email ( n = 1); and (6) an earlier study of the same cases were included in a follow-up study ( n = 2). Finally, 17 studies, including four cohort studies [11,21,22,23], one case series study [24], and 12 single-case reports [12,13,25,26,27,28,29,30,31,32,33,34], were selected and included in our systematic review (Figure 1).…”

“…The included studies were conducted in various countries from Asia and Europe, such as Japan ( n = 5) [11,26,27,28,29], Spain ( n = 3) [12,25,33], Taiwan ( n = 3) [21,23,30], India ( n = 2) [13,31], South Korea ( n = 1) [29], Italy ( n = 1) [33], Northern Ireland ( n = 1) [34], and Turkey ( n = 1) [22], and published from 1993 to 2018. Four cohort studies were included in this systematic review—three retrospective studies [11,22,23] and one prospective study [21].…”

Cloudy Dialysate as the Initial Presentation for Lymphoma

“…Chylous ascites is rare but is associated with several potentially life-threatening diagnoses including tuberculosis, pancreatitis [ 1 ], and malignancy [ 2 ]. The use of calcium channel blockers (CCBs), surgical trauma, and superior vena cava obstruction [ 3 , 4 ] has also presented with chylous ascites in peritoneal dialysis patients. In PD patients, the cloudy dialysate may lead to initiation of unnecessary antibiotics and delayed investigations.…”