P15
INTRAPERITONEAL STEROIDS FOR CULTURE NEGATIVE EOSINOPHILIC
PERITONITIS IN A CHILD ON PERITONEAL DIALYSIS – CASE REPORT AND
STABILITY STUDIES FOR SOLU-CORTEF® IN PHYSIONEAL® 40 AND
EXTRANEAL®
Ghinescu CE, Daglar T, Aragon O, Morgan H
Alder Hey Children’s Hospital, Liverpool
BACKGROUND: Eosinophilic peritonitis (EP) is a clinical diagnosis of peritoneal dialysis
(PD) peritonitis with >100 white blood cells (WBC)/mm3 (>0.1*109/L), more than 10% of these
being eosinophils. The aetiology of EP can be infectious (culture positive) or non infectious
(culture negative). The latter is thought to be due to an allergic reaction to the presence of
foreign material in the peritoneum (e.g. components of the dialysis system, the dialysate,
medications). It tends to appear in the first 3 months after catheter insertion, but has been
reported even after one year. Normally a self-limiting entity, various treatments (e.g. oral
steroids, oral antihistamines, intraperitoneal (IP) steroids) have been tried for culture negative
EP when the PD fluid was turbid enough to block the PD catheter or made dialysis difficult.
There are only two case reports that mention the use of intraperitoneal steroids in culture
negative EP, both in adults. We report here the first case of PD-associated, culture negative EP
treated with IP hydrocortisone in a child, and also compatibility and stability studies of Solucortef® hydrocortisone sodium succinate IV solution in Physioneal® 40 1.36% and 2.27% and
Extraneal® solutions.
CASE PRESENTATION: A five-year old girl, weighing 15.6 kg, BSA (body surface area)
0.66 m2, with steroid resistant nephrotic syndrome had a unilateral nephrectomy and PD
catheter insertion in January 2012. She started PD with Physioneal® 40. In July 2012 she was
diagnosed with peritonitis and received 2 weeks of IP antibiotics. A diagnosis of culture
negative eosinophilic peritonitis was given at the end of the antibiotic treatment as the
peritoneal fluid was still turbid with WBC 5.05*109/L, 4.69*109/L being eosinophils. She
developed soon symptoms of eczema and asthma. Skin prick tests to Physioneal® 40 were
negative. In November 2012, because she had three blockages of the PD catheter, she was
started on IP Solucortef® 75 mg in the 250 ml daytime dwell (0.3 mg/ml; 4.8 mg/kg body
weight; 113 mg/m2), initially in 0.9% saline. Stability studies showed when Solucortef® was
added to Physioneal® 40 1.36% or 2.27% at a concentration of 0.3 mg/ml, pH did not change
significantly over 24 hours (8.1 to 7.8). The hydrocortisone sodium succinate reduced by 5% in
both formulations but the hydrocortisone increased from 1.7% of total hydrocortisone content to
3.7%. Therefore the total hydrocortisone content at 24 hours was 97% of time zero.
Soon after the start of the IP hydrocortisone, the PD fluid became clear and the IP eosinophils
were undetectable. The dose of IP Solucortef® was decreased to 2.2 mg/kg in December 2012.
In Jan 2013 she developed cushingoid physical features and had a short admission to the
intensive care unit after a collapse at home with hypotension. A short Synacthen test showed a
suboptimal adrenal response. The IP steroids were reduced to 1.1 mg/kg in Feb then to 0.6
mg/kg in March 2013 and stopped the same month. Three weeks after stopping the IP steroids
she was diagnosed with Pseudomonas stutzeri peritonitis. The PD catheter was removed one
month later for persistent infection.
CONCLUSIONS: Culture negative eosinophilic peritonitis in patients on peritoneal dialysis
can be treated with IP steroids to allow the continued use of the PD catheter. The solution of
Solu-cortef® hydrocortisone sodium succinate and Physioneal® 40 (concentration tested 0.3
mg/ml) or Extraneal® (concentration tested 0.14 mg/ml) proved to be compatible and stable.
When using IP steroids care should be taken in regards to systemic steroid side effects (e.g.
cushingoid features, hypertension, ACTH suppression). A lower IP steroid dose may reduce
systemic side effect whilst maintaining catheter patency.