Non-infectious cloudy peritoneal fluid secondary to lercanidipine
Líquido peritoneal turbio no infeccioso secundario a lercanidipino
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She had high blood pressure and was on treatment with 320mg/day valsartan and 4mg/day doxazosin and was on peritoneal dialysis. She presented with cloudy peritoneal fluid. She did not complain of abdominal pain, fever or any other abdominal symptoms. Three days previously, 5mg/day lercanidipine had been added to her treatment. The appearance of the peritoneal fluid was milky and it did not contain fibrin. The cell count in the dialysate and the subsequent culture were negative. Plasma values for cholesterol and triglycerides (TG) were 189 and 175mg/dl, respectively and the dialysate value for TG was 20mg. Having ruled out bacterial peritonitis and given the potential relationship with lercanidipine, this drug was discontinued and 24 hours later, clear dialysate drainage was confirmed.</p><p class="elsevierStylePara">A few weeks later, the patient changed to automated peritoneal dialysis with a dry day, and with her consent, 5mg/day lercanidipine was reintroduced into her night dose.</p><p class="elsevierStylePara">One month later, she presented again with cloudy fluid without associated symptoms. Again, the cell count and culture of the dialysate were negative. On this occasion, TG was not measured in dialysate, but its plasma value was 145mg/dl (lower than in the previous episode). With the diagnosis of NICPF related to CCB, lercanidipine was discontinued. Again, the dialysate became clear over the next few hours.</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">NICPF is uncommon in peritoneal dialysis and its occurrence obliges us to carry out a differential diagnosis that must distinguish between clinical profiles with an increase in cellularity and acellular causes<span class="elsevierStyleSup">1,2</span>. The absence of cells rules out infection, inflammation, allergic reaction and bleeding. Fibrin, TG and drugs have been reported as the most common causes of acellular NICPF</p><p class="elsevierStylePara">CCB are amongst the drugs included. The oldest case was published in 1993 in relation to manidipine<span class="elsevierStyleSup">3</span>, the drug most commonly involved, although other CCB, most of them dihydropyridines, can also trigger it<span class="elsevierStyleSup">4</span>. Since the appearance of new CCB, cases of secondary NICPF have been published fairly frequently.<span class="elsevierStyleSup">5,6</span>. Curiously, classic types of CCB do not cause it or do so less frequently<span class="elsevierStyleSup">7</span>. This has led us to believe that the characteristics of the different CCB may influence the occurrence of NICPF.</p><p class="elsevierStylePara">CCB-induced NICPF is defined as<span class="elsevierStyleSup">4</span>: cloudiness of the dialysate that appears 48-72 hours after the administration of the drug, with the absence of peritoneal inflammatory signs and symptoms and a negative cell count and peritoneal fluid culture, which disappears spontaneously after the drug is discontinued. Unlike infectious peritonitis, some authors have noted an increase in ultrafiltration during the episode<span class="elsevierStyleSup">8</span>.</p><p class="elsevierStylePara">The cloudiness of the peritoneal fluid, which is characteristically milky, is due to the presence of TG (normally almost non-existent in the dialysate if there is no other cause), although they do not always reach chyloperitoneum levels (>100mg/dl). The mechanism whereby TG increase is still unknown, although there has been speculation that it may be due to a disorder of its degradation in the peritoneum or the reduction of lymphatic stomata in the diaphragmatic peritoneum<span class="elsevierStyleSup">3,8</span>. It has been noted that TG in dialysate seem to have a direct relationship with TG levels in blood<span class="elsevierStyleSup">9</span>. Lercanidipine acts both in the smooth muscle cells of blood vessels and of the lymphatic system and the digestive tract, which may explain its effect<span class="elsevierStyleSup">9</span>.</p><p class="elsevierStylePara">Reports of NICPF secondary to lercanidipine have a curious geographic distribution: the few cases reported have occurred in Asia<span class="elsevierStyleSup">8-10</span>, and the closest to Europe are located in the Asian region of Turkey<span class="elsevierStyleSup">11</span>. Although it has been much used in Europe for years, we have not found reported cases of NICPF related to its use (in contrast to the high incidence of cases related to manidipine). This has made us consider that racial factors or genetic predisposition may be involved<span class="elsevierStyleSup">8,9</span>.</p><p class="elsevierStylePara">Apart from the unsettling effect, the presence of NICPF does not seem to have any negative clinical repercussions. In fact, Yang reported two patients who remained on lercanidipine in whom the cloudiness gradually disappeared<span class="elsevierStyleSup">9</span>.</p><p class="elsevierStylePara">In our case, all the data support our diagnosis of NICPF secondary to lercanidipine. In the second episode, the delay in the reappearance of peritoneal cloudiness was surprising, which we thought could be related to the absence of dialysate in the peritoneal cavity during the daytime.</p><p class="elsevierStylePara">In summary, in the presence of acellular NICPF, we must rule out the potential relationship with CCB in order to avoid unnecessary antibiotic treatment.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">The authors declare that they have no conflicts of interest related to the contents of this article.</p>" "pdfFichero" => "P1-E574-S4714-A12500-EN.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Rocklin MA, Teitelbaum I. 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|---|---|---|---|
| 2024 November | 1 | 4 | 5 |
| 2024 October | 76 | 59 | 135 |
| 2024 September | 77 | 28 | 105 |
| 2024 August | 103 | 66 | 169 |
| 2024 July | 78 | 29 | 107 |
| 2024 June | 104 | 47 | 151 |
| 2024 May | 105 | 82 | 187 |
| 2024 April | 78 | 29 | 107 |
| 2024 March | 70 | 33 | 103 |
| 2024 February | 42 | 42 | 84 |
| 2024 January | 55 | 26 | 81 |
| 2023 December | 45 | 31 | 76 |
| 2023 November | 62 | 39 | 101 |
| 2023 October | 76 | 33 | 109 |
| 2023 September | 73 | 25 | 98 |
| 2023 August | 68 | 23 | 91 |
| 2023 July | 73 | 36 | 109 |
| 2023 June | 68 | 23 | 91 |
| 2023 May | 87 | 38 | 125 |
| 2023 April | 44 | 16 | 60 |
| 2023 March | 70 | 29 | 99 |
| 2023 February | 69 | 29 | 98 |
| 2023 January | 75 | 24 | 99 |
| 2022 December | 79 | 42 | 121 |
| 2022 November | 79 | 30 | 109 |
| 2022 October | 85 | 45 | 130 |
| 2022 September | 76 | 27 | 103 |
| 2022 August | 87 | 47 | 134 |
| 2022 July | 58 | 47 | 105 |
| 2022 June | 67 | 26 | 93 |
| 2022 May | 134 | 41 | 175 |
| 2022 April | 120 | 61 | 181 |
| 2022 March | 110 | 57 | 167 |
| 2022 February | 97 | 53 | 150 |
| 2022 January | 103 | 34 | 137 |
| 2021 December | 100 | 33 | 133 |
| 2021 November | 93 | 43 | 136 |
| 2021 October | 150 | 48 | 198 |
| 2021 September | 118 | 46 | 164 |
| 2021 August | 146 | 50 | 196 |
| 2021 July | 107 | 59 | 166 |
| 2021 June | 93 | 43 | 136 |
| 2021 May | 107 | 34 | 141 |
| 2021 April | 306 | 68 | 374 |
| 2021 March | 170 | 46 | 216 |
| 2021 February | 150 | 29 | 179 |
| 2021 January | 87 | 20 | 107 |
| 2020 December | 82 | 22 | 104 |
| 2020 November | 71 | 17 | 88 |
| 2020 October | 105 | 27 | 132 |
| 2020 September | 77 | 10 | 87 |
| 2020 August | 122 | 16 | 138 |
| 2020 July | 105 | 13 | 118 |
| 2020 June | 114 | 14 | 128 |
| 2020 May | 93 | 15 | 108 |
| 2020 April | 86 | 23 | 109 |
| 2020 March | 89 | 11 | 100 |
| 2020 February | 96 | 21 | 117 |
| 2020 January | 111 | 14 | 125 |
| 2019 December | 130 | 25 | 155 |
| 2019 November | 86 | 22 | 108 |
| 2019 October | 88 | 13 | 101 |
| 2019 September | 106 | 26 | 132 |
| 2019 August | 84 | 20 | 104 |
| 2019 July | 105 | 15 | 120 |
| 2019 June | 90 | 33 | 123 |
| 2019 May | 87 | 20 | 107 |
| 2019 April | 104 | 28 | 132 |
| 2019 March | 80 | 32 | 112 |
| 2019 February | 57 | 19 | 76 |
| 2019 January | 71 | 16 | 87 |
| 2018 December | 92 | 33 | 125 |
| 2018 November | 165 | 20 | 185 |
| 2018 October | 95 | 12 | 107 |
| 2018 September | 88 | 13 | 101 |
| 2018 August | 76 | 10 | 86 |
| 2018 July | 66 | 19 | 85 |
| 2018 June | 72 | 13 | 85 |
| 2018 May | 71 | 14 | 85 |
| 2018 April | 84 | 8 | 92 |
| 2018 March | 82 | 9 | 91 |
| 2018 February | 61 | 7 | 68 |
| 2018 January | 53 | 8 | 61 |
| 2017 December | 71 | 7 | 78 |
| 2017 November | 70 | 10 | 80 |
| 2017 October | 60 | 7 | 67 |
| 2017 September | 68 | 19 | 87 |
| 2017 August | 71 | 21 | 92 |
| 2017 July | 70 | 15 | 85 |
| 2017 June | 71 | 7 | 78 |
| 2017 May | 71 | 7 | 78 |
| 2017 April | 71 | 14 | 85 |
| 2017 March | 57 | 3 | 60 |
| 2017 February | 47 | 8 | 55 |
| 2017 January | 30 | 10 | 40 |
| 2016 December | 92 | 15 | 107 |
| 2016 November | 126 | 14 | 140 |
| 2016 October | 174 | 13 | 187 |
| 2016 September | 184 | 3 | 187 |
| 2016 August | 290 | 3 | 293 |
| 2016 July | 305 | 5 | 310 |
| 2016 June | 163 | 0 | 163 |
| 2016 May | 159 | 0 | 159 |
| 2016 April | 145 | 0 | 145 |
| 2016 March | 94 | 0 | 94 |
| 2016 February | 110 | 0 | 110 |
| 2016 January | 135 | 0 | 135 |
| 2015 December | 122 | 0 | 122 |
| 2015 November | 102 | 0 | 102 |
| 2015 October | 91 | 0 | 91 |
| 2015 September | 97 | 0 | 97 |
| 2015 August | 74 | 0 | 74 |
| 2015 July | 88 | 0 | 88 |
| 2015 June | 45 | 0 | 45 |
| 2015 May | 66 | 0 | 66 |
| 2015 April | 19 | 0 | 19 |
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