Cola-Colored Peritoneal Dialysate in a Patient with Impella Device-Associated Hemolysis

Introduction: In PD patients, Cola-colored effluent is a rare and ominous complication, which is usually associated with rhabdomyolysis or hemorrhagic pancreatitis, noted prior cases were fatal. The mechanism by which this occurs is thought to be as a result of breakdown of heme from hemoglobin and myoglobin, subsequent reaction of hemin with albumin to form methemalbumin. This case presents a novel occurrence, as hemolytic anemia from Impella placement resulted in cola-colored dialysate. Case Description: 48-year-old male with ESRD on PD, CAD s/p multiple PCI and recent DES placement, and HFrEF, who was found to have NSTEMI. He underwent cardiac catheterization with findings of diffuse mvCAD. He developed worsening cardiogenic shock, was transitioned to CRRT – an axillary Impella device was placed on hospital day 12. He was noted to have pink CRRT effluent suggestive of hemolysis, suspected to be due to malposition of the Impella device. The Impella was repositioned with ultrasound guidance. The patient had unconjugated bilirubinemia to 17.0 mg/dL, serum LDH 5866 U/L, and lactic acidosis. PD fluid was drawn to rule out infection, and noted to be dark brown in coloration. The fluid resulted with negative gram stain and culture, however total bilirubin of the fluid was 6.2 mg/dL, LDH was 1626 U/L. Patient had clear peritoneal dialysate until this point. Discussion: This case of dark PD fluid discoloration was not associated with any of the previously documented risk factors, and is instead associated with hemolysis from impella placement, which is a novel occurrence. The presence of dark discoloration or bilirubin in the dialysate should prompt rule-out of intra-peritoneal sources of heme or bile, and is considered an ominous clinical sign. All documented cases have been fatal, and this patient also expired from complications of refractory shock.