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Icodextrin-Induced Sterile Peritonitis: The Israeli Experience

Peritonitis in the peritoneal dialysis (PD) patient is defined by the International Society for Peritoneal Dialysis as the presence of two of the following three criteria: (1) signs and symptoms of peritoneal irritation such as fever, abdominal pain/tenderness; (2) a turbid effluent containing >100 white blood cells (WBC)/μL, of which >50% are neutrophils; and (3) identification of the organism in the dialysate (1). However, in up to 20% of cases, cultures of cloudy dialysate fluid prove to be negative and these patients are referred to as having aseptic, culture-negative, or sterile peritonitis. The causes of sterile peritonitis are many and they have been extensively reviewed in the literature (2–6). They have been classified according to the effluent cell count and type into cellular and noncellular causes (7). This report, however, will focus on icodextrin-induced sterile peritonitis as it occurred in Israel. Icodextrin (Extraneal; Baxter, Castlebar, Ireland) PD solution is a glucose polymer operating on the principle of colloid osmosis and is used mainly to augment ultrafiltration. The first cases of icodextrin-induced sterile peritonitis were reported in 1999 (7) and reached epidemic proportions during the first 6 months of 2002 (8). Most reports originated in Europe. During 2003 – 2004, a series of cases compatible with the diagnosis of icodextrin-induced sterile peritonitis appeared in Israel. The aims of this retrospective work were to describe the features of icodextrin-induced sterile peritonitis and to highlight the fact that this entity should be considered in the differential diagnosis of culture-negative peritonitis in PD patients.