Green Peritoneal Dialysis Fluid

This month's Kidney International "Nephrology Image" features a report by Chen et al in which they describe a PD patient who noted cloudy, deep green dialysate fluid upon drainage of their peritoneum. They also presented with right upper quadrant pain and fever. Peritoneal white cell count was elevated with 84% neutrophils. The diagnosis? Gallstone peritonitis. The patient had a distended gall bladder with multiple pigmented stones; the greenish color is presumably from extravasated bile fluid. The authors make the case that "appearance of green color in the peritoneal dialysate should lead to immediate investigation of the biliary tract in patients with our without abdominal symptoms [as] asymptomatic perforation of the gall bladder has previously been reported."