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Nakao M, Yokoyama K, Yamamoto I, Matsuo N, Tanno Y, Ohkido I, Hayakawa H, Ikeda M, Yamamoto H, Hosoya T. Risk Factors for Encapsulating Peritoneal Sclerosis in Long-Term Peritoneal Dialysis: A Retrospective Observational Study. Ther Apher Dial 2013; 18:68-73. [DOI: 10.1111/1744-9987.12048] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Masatsugu Nakao
- Department of Internal Medicine; Division of Kidney and Hypertension; The Jikei University School of Medicine; Tokyo Japan
| | - Keitaro Yokoyama
- Department of Internal Medicine; Division of Kidney and Hypertension; The Jikei University School of Medicine; Tokyo Japan
| | - Izumi Yamamoto
- Department of Internal Medicine; Division of Kidney and Hypertension; The Jikei University School of Medicine; Tokyo Japan
| | - Nanae Matsuo
- Department of Internal Medicine; Division of Kidney and Hypertension; The Jikei University School of Medicine; Tokyo Japan
| | - Yudo Tanno
- Department of Internal Medicine; Division of Kidney and Hypertension; The Jikei University School of Medicine; Tokyo Japan
| | - Ichiro Ohkido
- Department of Internal Medicine; Division of Kidney and Hypertension; The Jikei University School of Medicine; Tokyo Japan
| | - Hiroshi Hayakawa
- Department of Internal Medicine; Division of Kidney and Hypertension; The Jikei University School of Medicine; Tokyo Japan
| | - Masato Ikeda
- Department of Internal Medicine; Division of Kidney and Hypertension; The Jikei University School of Medicine; Tokyo Japan
| | - Hiroyasu Yamamoto
- Department of Internal Medicine; Division of Kidney and Hypertension; The Jikei University School of Medicine; Tokyo Japan
| | - Tatsuo Hosoya
- Department of Internal Medicine; Division of Kidney and Hypertension; The Jikei University School of Medicine; Tokyo Japan
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An intra-abdominal abscess or "rind" as a consequence of peritoneal dialysis-associated pseudomonas peritonitis. Clin Nephrol Case Stud 2013; 1:1-6. [PMID: 29043117 PMCID: PMC5437986 DOI: 10.5414/cncs107951] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Accepted: 01/22/2013] [Indexed: 11/21/2022] Open
Abstract
Background: Abdominal CT imaging has defined characteristics of two pathological entities specific to peritoneal dialysis patients. Both are associated with serious peritoneal complications. One is comprised of ascites accompanied by septation and loculated fluid pockets as a complication of bacterial peritonitis. The other is the syndrome of encapsulating peritoneal sclerosis. We present the evolution of a single, thick-walled fluid collection as a consequence of relapsing Pseudomonas aeruginosa peritonitis. The entity had distinctive features differing from either of the two previously described entities, and to our knowledge, has not been described previously. Our patient’s radiological evolution resembled the formation of a pleural or peritoneal “rind.” Conclusion: Peritonitis, as a result of Pseudomonas aeruginosa, may lead to “rind” formation as described with empyemas and is distinct from previously described intra-abdominal pathologies in peritoneal dialysis patients.
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Transcriptional patterns in peritoneal tissue of encapsulating peritoneal sclerosis, a complication of chronic peritoneal dialysis. PLoS One 2013; 8:e56389. [PMID: 23418565 PMCID: PMC3572070 DOI: 10.1371/journal.pone.0056389] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Accepted: 12/27/2012] [Indexed: 12/26/2022] Open
Abstract
Encapsulating peritoneal sclerosis (EPS) is a devastating complication of peritoneal dialysis (PD), characterized by marked inflammation and severe fibrosis of the peritoneum, and associated with high morbidity and mortality. EPS can occur years after termination of PD and, in severe cases, leads to intestinal obstruction and ileus requiring surgical intervention. Despite ongoing research, the pathogenesis of EPS remains unclear. We performed a global transcriptome analysis of peritoneal tissue specimens from EPS patients, PD patients without EPS, and uremic patients without history of PD or EPS (Uremic). Unsupervised and supervised bioinformatics analysis revealed distinct transcriptional patterns that discriminated these three clinical groups. The analysis identified a signature of 219 genes expressed differentially in EPS as compared to PD and Uremic groups. Canonical pathway analysis of differentially expressed genes showed enrichment in several pathways, including antigen presentation, dendritic cell maturation, B cell development, chemokine signaling and humoral and cellular immunity (P value<0.05). Further interactive network analysis depicted effects of EPS-associated genes on networks linked to inflammation, immunological response, and cell proliferation. Gene expression changes were confirmed by qRT-PCR for a subset of the differentially expressed genes. EPS patient tissues exhibited elevated expression of genes encoding sulfatase1, thrombospondin 1, fibronectin 1 and alpha smooth muscle actin, among many others, while in EPS and PD tissues mRNAs encoding leptin and retinol-binding protein 4 were markedly down-regulated, compared to Uremic group patients. Immunolocalization of Collagen 1 alpha 1 revealed that Col1a1 protein was predominantly expressed in the submesothelial compact zone of EPS patient peritoneal samples, whereas PD patient peritoneal samples exhibited homogenous Col1a1 staining throughout the tissue samples. The results are compatible with the hypothesis that encapsulating peritoneal sclerosis is a distinct pathological process from the simple peritoneal fibrosis that accompanies all PD treatment.
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Latus J, Ulmer C, Fritz P, Rettenmaier B, Biegger D, Lang T, Ott G, Kimmel M, Steurer W, Alscher MD, Segerer S, Braun N. Phenotypes of encapsulating peritoneal sclerosis--macroscopic appearance, histologic findings, and outcome. Perit Dial Int 2013; 33:495-502. [PMID: 23378473 DOI: 10.3747/pdi.2012.00019] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Encapsulating peritoneal sclerosis (EPS) is a rare but devastating complication of peritoneal dialysis (PD), with clinical signs of abdominal pain, bowel obstruction, and weight loss in late stages. METHODS We retrospectively analyzed all patients who were diagnosed with EPS between March 1998 and October 2011 in our department of nephrology. We focused on the 24 EPS patients who underwent surgery because of symptomatic late-stage EPS. We identified 3 different macroscopic phenotypes of EPS that we categorized as types I - III. We correlated histologic findings with those macroscopic phenotypes of EPS. The postoperative and long-term outcomes were evaluated by macroscopic phenotype. RESULTS Duration of PD was longer in type III than in types I and II EPS (p = 0.05). We observed no other statistically significant differences between the groups in baseline characteristics, except for operation time, which was longer in the type I than in the type III group (p = 0.02). Furthermore, we observed no statistically significant difference between the groups with respect to the onset of complaints before surgery (7.8 ± 5.9 months vs 7.0 ± 7.0 months vs 6.5 ± 5.3 months). Concerning patient outcomes, there was no evidence that any of the macroscopic EPS types was associated with more major or minor complications after surgery. For all study patients, follow-up was at least 3 years, with 19 patients still being alive, and 16 having no or very mild complaints. The typical histologic findings of EPS were present in all macroscopic types; only fibrin deposits were more prominent in type II than in type III. CONCLUSIONS We describe 3 subtypes of EPS based on macroscopic findings. Postoperative treatment should probably not be influenced by the macroscopic EPS phenotype. Whether the different phenotypes represent different pathophysiologic processes remains unclear and has to be further evaluated.
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Affiliation(s)
- Joerg Latus
- Department of Internal Medicine,1 Division of Nephrology, Robert-Bosch-Hospital, and Department of General, Visceral and Trauma Surgery,2 Robert-Bosch-Hospital, Stuttgart, Germany
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Shroff R, Stefanidis CJ, Askiti V, Edefonti A, Testa S, Ekim M, Kavaz A, Ariceta G, Bakkaloglu S, Fischbach M, Klaus G, Zurowska A, Holtta T, Jankauskiene A, Vondrak K, Walle JV, Schmitt CP, Watson AR. Encapsulating peritoneal sclerosis in children on chronic PD: a survey from the European Paediatric Dialysis Working Group. Nephrol Dial Transplant 2013; 28:1908-14. [DOI: 10.1093/ndt/gfs603] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Rukshana Shroff
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | | | | | - Sara Testa
- Clinica Pediatrica De Marchi, Milan, Italy
| | | | - Asli Kavaz
- Ankara University Hospital, Ankara, Turkey
| | | | | | | | | | | | | | | | | | | | | | - Alan R. Watson
- Nottingham University Hospitals NHS Trust, Nottingham, UK
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Habib SM, Korte MR, Betjes MGH. Lower mortality and inflammation from post-transplantation encapsulating peritoneal sclerosis compared to the classical form. Am J Nephrol 2013; 37:223-30. [PMID: 23467015 DOI: 10.1159/000348267] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 01/22/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND Encapsulating peritoneal sclerosis (EPS) may occur after kidney transplantation (post-transplantation EPS) or may be diagnosed during or after peritoneal dialysis treatment (classical EPS). The aim of the present study was to investigate to what extent both EPS entities differ in clinical presentation, radiological findings, outcome, and the systemic inflammatory response, as measured by plasma C-reactive protein (CRP) levels both prior to and after EPS diagnosis. METHODS We performed a retrospective analysis of 15 post-transplantation EPS and 19 classical EPS patients who were diagnosed at seven hospitals in the Netherlands between January 1, 2000, and January 1, 2011. RESULTS There were no inter-group differences in age, duration of peritoneal dialysis, clinical presentation, or radiology findings at diagnosis. Post-transplantation patients had experienced a lower number of peritonitis episodes per patient-year (0.2 (0.0-0.4) vs. 0.7 (0.3-1.2), p = 0.01) with a longer interval between the last peritonitis and EPS diagnosis (18.1 (4.6-34.3) vs. 4.4 (0.89-13.78) months, p = 0.01). Post-transplantation EPS patients showed a remarkably lower mortality rate (40.0 vs. 84.2%, p < 0.05). In both groups a pattern of elevated CRP values was observed, increasing within the year before EPS diagnosis. In the post-transplantation group the median CRP level at diagnosis was lower (56.0 vs. 144.50 mg/l, p < 0.05) than in the classical EPS group. CONCLUSION Post-transplantation EPS has a similar clinical presentation as classical EPS but with a lower systemic inflammatory response and better outcome.
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Affiliation(s)
- Sayed M Habib
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
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Braun N, Fritz P, Ulmer C, Latus J, Kimmel M, Biegger D, Ott G, Reimold F, Thon KP, Dippon J, Segerer S, Alscher MD. Histological criteria for encapsulating peritoneal sclerosis - a standardized approach. PLoS One 2012; 7:e48647. [PMID: 23144917 PMCID: PMC3492493 DOI: 10.1371/journal.pone.0048647] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 09/27/2012] [Indexed: 12/11/2022] Open
Abstract
Background The two most relevant pathologies of long-term peritoneal dialysis (PD) are simple sclerosis and encapsulating peritoneal sclerosis (EPS). The histological differentiation of those two entities is difficult. The Aim of the study was to establish a method to standardize and facilitate the differentiation between simple sclerosis and EPS Methods We investigated 58 peritoneal biopsies - 31 EPS patients and 27 PD patients. Two blinded investigators analyzed 20 histological characteristics in EPS and PD patients. Results The following findings were significantly more common in EPS than in patients on PD without EPS: fibroblast like cells (FLC) (p<0.0001), mesothelial denudation (p<0.0001), decreased cellularity (p = 0.008), fibrin deposits (p<0.03), Fe deposits (p = 0.05), podoplanin vascular (p<0.0001), podoplanin avascular (p<0.0001). Using all predictor variables we trained the classification method Random Forest to categorize future cases. Podoplanin vascular and avascular were taken together (p<0.0001), FLC (p<0.0001), mesothelial denudation (p = 0.0005), calcification (p = 0.0026), acellular areas (p = 0.0094), and fibrin deposits (p = 0.0336) showed up as significantly important predictor variables. Estimated misclassification error rate when classifying new cases turned out to be 14%. Conclusion The introduced statistical method allows discriminating between simple sclerosis and EPS. The misclassification error will likely improve with every new case added to the database.
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Affiliation(s)
- Niko Braun
- Department of Internal Medicine, Division of Nephrology, Robert Bosch Hospital, Stuttgart, Germany
| | - Peter Fritz
- Margarete Fischer–Bosch Institute of Clinical Pharmacology, University of Tuebingen, Tuebingen, Germany
| | - Christoph Ulmer
- Department of Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | - Joerg Latus
- Department of Internal Medicine, Division of Nephrology, Robert Bosch Hospital, Stuttgart, Germany
- * E-mail:
| | - Martin Kimmel
- Department of Internal Medicine, Division of Nephrology, Robert Bosch Hospital, Stuttgart, Germany
| | - Dagmar Biegger
- Margarete Fischer–Bosch Institute of Clinical Pharmacology, University of Tuebingen, Tuebingen, Germany
| | - German Ott
- Department of Diagnostic Medicine, Division of Pathology, Robert Bosch Hospital, Stuttgart, Germany
| | - Fabian Reimold
- Department of Internal Medicine, Division of Nephrology, Robert Bosch Hospital, Stuttgart, Germany
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
| | - Klaus-Peter Thon
- Department of Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | - Juergen Dippon
- Department of Mathematics, University of Stuttgart, Stuttgart, Germany
| | - Stephan Segerer
- Division of Nephrology, University Hospital, Zurich, Switzerland
| | - M. Dominik Alscher
- Department of Internal Medicine, Division of Nephrology, Robert Bosch Hospital, Stuttgart, Germany
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Marinangeli G, Cabiddu G, Neri L, Viglino G, Russo R, Teatini U. Old and new perspectives on peritoneal dialysis in Italy emerging from the Peritoneal Dialysis Study Group Census. Perit Dial Int 2012; 32:558-65. [PMID: 22383633 PMCID: PMC3524866 DOI: 10.3747/pdi.2011.00112] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Accepted: 09/21/2011] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND To understand how peritoneal dialysis (PD) was being used in Italy in 2005 and 2008, a census of all centers was carried out. METHODS In 2005 and 2008, data were collected from, respectively, 222 and 223 centers, with respect to 4432 and 4094 prevalent patients. RESULTS In the two periods, the PD incidence remained stable (24.3% vs 22.9%), varying from center to center. Continuous ambulatory PD (CAPD) was the main initial method (55%), but APD was more widespread among prevalent patients (53%). Among patients returning to dialysis from transplantation (Tx), PD was used in 10%. The use of incremental CAPD increased significantly from 2005 to 2008, in terms both of the number of centers (27.0% vs 40.9%) and of patients (13.6% vs 25.7%). Late referrals remained stable at 28%, with less use of PD. The overall drop-out rate (episodes/100 patient-years) remained unchanged (31.0 vs 32.8), with 13.1 and 12.9 being the result of death, and 11.8 and 12.4 being the result of a switch to hemodialysis, mainly after peritonitis. A dialysis partner was required by 21.8% of the PD patients. The incidence of peritonitis was 1 episode in 36.5 and 41.1 patient-months, with negative cultures occurring in 17.1% of cases in both periods. The incidence of encapsulating peritoneal sclerosis (episodes/100 patient-years) was 0.70, representing 1.26% of patients treated. The catheter types used and the sites and methods of insertion varied widely from center to center. CONCLUSIONS These censuses confirm the good results of PD in Italy, and provide insight into little-known aspects such as the use of incremental PD, the presence of a dialysis partner, and the incidence of encapsulating peritoneal sclerosis.
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Margetts PJ, Hoff C, Liu L, Korstanje R, Walkin L, Summers A, Herrick S, Brenchley P. Transforming growth factor β-induced peritoneal fibrosis is mouse strain dependent. Nephrol Dial Transplant 2012; 28:2015-27. [PMID: 22785109 DOI: 10.1093/ndt/gfs289] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Encapsulating peritoneal sclerosis (EPS) is a rare but devastating complication of peritoneal dialysis. The etiology is unclear, but genetic predisposition may be a contributing factor. We used adenovirus-mediated gene transfer of transforming growth factor (TGF) β1 to the peritoneum in four genetically distinct laboratory mouse strains to assess differences in fibrogenic response. METHODS Mice from four genetic backgrounds (C57BL/6J, DBA/2J, C3H/HeJ and SJL/J) received an intraperitoneal injection of an adenovirus expressing TGFβ1 (AdTGFβ1) or control adenovirus (AdDL) and were assessed 4 and 10 days after infection. Submesothelial thickening, angiogenesis and gene expression were quantified from peritoneal tissue. Protein was extracted from omental tissue and assessed for collagen, E-cadherin and TGFβ signaling pathway proteins. RESULTS There was a graded response among the mouse strains to the peritoneal overexpression of TGFβ1. TGFβ1 induced a significant fibrogenic response in the C57BL/6J mice, whereas the SJL/J mice were resistant. The DBA/2J and the C3H/HeJ mice had intermediate responses. A similar graded response was seen in collagen protein levels in the omental tissue and in fibrosis-associated gene expression. TGFβ type 1 receptor and SMAD signaling pathways appeared to be intact in all the mouse strains. CONCLUSIONS There were significant differences in mouse strain susceptibility to peritoneal fibrosis, suggesting that genetic factors may play a role in the development of peritoneal fibrosis and possibly EPS. As early TGFβ1 signaling mechanisms appear to be intact, we hypothesize that fibrosis resistance in the SJL/J mice lies further down the wound-healing cascade or in an alternate, non-SMAD pathway.
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Affiliation(s)
- Peter J Margetts
- Department of Nephrology, McMaster University, Hamilton, Ontario, Canada
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112
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Latus J, Ulmer C, Fritz P, Rettenmaier B, Biegger D, Lang T, Ott G, Scharpf C, Kimmel M, Steurer W, Alscher MD, Braun N. Encapsulating peritoneal sclerosis: a rare, serious but potentially curable complication of peritoneal dialysis–experience of a referral centre in Germany. Nephrol Dial Transplant 2012; 28:1021-30. [DOI: 10.1093/ndt/gfs159] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Tannoury JN, Abboud BN. Idiopathic sclerosing encapsulating peritonitis: Abdominal cocoon. World J Gastroenterol 2012; 18:1999-2004. [PMID: 22563185 PMCID: PMC3342596 DOI: 10.3748/wjg.v18.i17.1999] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Revised: 02/20/2012] [Accepted: 02/26/2012] [Indexed: 02/06/2023] Open
Abstract
Abdominal cocoon, the idiopathic form of sclerosing encapsulating peritonitis, is a rare condition of unknown etiology that results in an intestinal obstruction due to total or partial encapsulation of the small bowel by a fibrocollagenous membrane. Preoperative diagnosis requires a high index of clinical suspicion. The early clinical features are nonspecific, are often not recognized and it is difficult to make a definite pre-operative diagnosis. Clinical suspicion may be generated by the recurrent episodes of small intestinal obstruction combined with relevant imaging findings and lack of other plausible etiologies. The radiological diagnosis of abdominal cocoon may now be confidently made on computed tomography scan. Surgery is important in the management of this disease. Careful dissection and excision of the thick sac with the release of the small intestine leads to complete recovery in the vast majority of cases.
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Affiliation(s)
- Peter G Blake
- Division of Nephrology, University of Western Ontario, London, Ontario, Canada.
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115
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Summers AM, Abrahams AC, Alscher MD, Betjes M, Boeschoten EW, Braun N, Brenchley PEC, Davies S, Dunn L, Engelsman L, Fieren M, Garosi G, Goffin E, Heuveling L, Korte M, Lindholm B, Rutherford P, Struijk D, Verduijn M, Verger C, Westerhuis R. A collaborative approach to understanding EPS: the European perspective. Perit Dial Int 2012; 31:245-8. [PMID: 21555409 DOI: 10.3747/pdi.2010.00086] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Angela M Summers
- Department of Renal Research, Manchester Royal Infirmary, Manchester, UK.
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The 2010 Nephrology Quiz and Questionnaire. Clin J Am Soc Nephrol 2011. [DOI: 10.2215/01.cjn.0000927136.72811.f9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
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Ryckelynck JP, Abbadie O, Castrale C, Lavainne F, Fakhouri F, Lobbedez T. [Why and how to promote peritoneal dialysis?]. Presse Med 2011; 40:1053-8. [PMID: 21924862 DOI: 10.1016/j.lpm.2011.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Accepted: 06/10/2011] [Indexed: 11/26/2022] Open
Abstract
The prevalence of peritoneal dialysis in France remains one of the lowest in Europe in spite of official recommendations in 2008. Progress in peritoneal catheter placement and a good knowledge of the management of catheter complications are essential. A more frequent use of biocompatible solutions should achieve a better preservation of the peritoneal membrane. Such physiological peritoneal fluids seem to decrease morbidity and mortality. Best peritoneal dialysis indications are mainly young patients waiting for a kidney transplantation, old patients without malnutrition and patients with cardiac insufficiency. Objective and complete information dedicated to both peritoneal dialysis and hemodialysis is necessary, even for patients seen in emergency or unplanned or late referral patients. A pre-end-stage renal disease education program has to be mandatory. Non-medical obstacles, mainly financial, are still common so that economic incitations are necessary for the development of peritoneal dialysis. A university formation of nephrologists is now available.
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Glassock RJ, Bleyer AJ, Bargman JM, Fervenza FC. The 2010 nephrology quiz and questionnaire: part 2. Clin J Am Soc Nephrol 2011; 6:2534-47. [PMID: 21903985 DOI: 10.2215/cjn.06500711] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Presentation of the Nephrology Quiz and Questionnaire (NQQ) has become an annual "tradition" at the meetings of the American Society of Nephrology. It is a very popular session judged by consistently large attendance. Members of the audience test their knowledge and judgment on a series of case-oriented questions prepared and discussed by experts. They can also compare their answers in real time, using audience response devices, to those of program directors of nephrology training programs in the United States, acquired through an Internet-based questionnaire. As in the past, the topics covered were transplantation, fluid and electrolyte disorders, end-stage renal disease and dialysis, and glomerular disorders. Two challenging cases representing each of these categories along with single best answer questions were prepared by a panel of experts (Drs. Hricik, Palmer, Bargman, and Fervenza, respectively). The "correct" and "incorrect" answers then were briefly discussed, after the audience responses and the results of the questionnaire were displayed. The 2010 version of the NQQ was exceptionally challenging, and the audience, for the first time, gained a better overall correct answer score than the program directors, but the margin was small. Last month we presented the transplantation and fluid and the electrolyte cases; in this issue we present the remaining end-stage renal disease and dialysis and the glomerular disorder cases. These articles try to recapitulate the session and reproduce its educational value for a larger audience--that of the readers of the Clinical Journal of the American Society of Nephrology. Have fun.
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Abstract
Encapsulating peritoneal sclerosis (EPS) is a rare complication of peritoneal dialysis (PD), but carries significant morbidity and mortality. We review the clinical features and radiologic and histologic changes found at diagnosis of EPS. Although EPS is strongly associated with the duration of PD, the pathogenesis remains only partly understood. We discuss the mechanisms thought to underlie the abnormally thickened, sclerotic peritoneal membrane seen in long-term PD patients including epithelial to mesenchymal transition and the molecular mediators of fibrosis and angiogenesis. We review how exposure to high-glucose, nonphysiological dialysis fluids, peritonitis, and uremia may be responsible for these changes. Much remains to be learned about optimal management of EPS, both medical and surgical, because the literature lacks controlled studies. Future research challenges include defining the role of surgery, immunosuppression, and antifibrotic agents in the management of EPS. We also need to understand why some patients progress from asymptomatic peritoneal sclerosis to the extreme levels of fibrin deposition and bowel encapsulation seen in EPS. Screening PD patients for potential future EPS remains difficult, and we need strategies for monitoring patients on longer-term PD that enable us to better quantify the risk of EPS for the individual patient.
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Affiliation(s)
- Catriona Goodlad
- Imperial College Kidney and Transplant Institute, Hammersmith Hospital, London, UK.
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120
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Abstract
Changes to peritoneal membrane function over time result in the development of ultrafiltration failure in a proportion of PD patients and pose a risk for the rarer condition of encapsulating peritoneal sclerosis. These changes are characterized by an increase in the transport rate for small solutes owing to increased vascularity and/or peritoneal blood flow and in more severe cases a reduction in the osmotic conductance of the membrane that likely reflects progressive fibrosis. Both of these processes are preceded by exposure of the membrane to glucose when using conventional dialysis solutions, although this usually is necessitated and likely exacerbated by loss of residual renal function and recurrent peritonitis. Mediators of membrane injury and thus potential biomarkers include inflammatory cytokines, notably local interleukin-6 production, which also appears to determine solute transport characteristics at the start of peritoneal dialysis, local production of vascular endothelial growth factor, and transforming growth factor β-associated epithelial to mesenchymal transition of the mesothelium leading to membrane fibrosis. Low glucose degradation product solutions may ameliorate the mesothelial injury associated with high glucose exposure, but evidence that they prevent or delay changes in membrane function over time is lacking. In the meantime, avoidance of excessive glucose exposure, preservation of residual renal function, and prevention of peritonitis remain the most logical treatment strategies for this problem.
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Affiliation(s)
- Simon J Davies
- Department of Nephrology, University Hospital of North Staffordshire, Stoke on Trent, Staffordshire, UK.
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Korte MR, Sampimon DE, Betjes MGH, Krediet RT. Encapsulating peritoneal sclerosis: the state of affairs. Nat Rev Nephrol 2011; 7:528-38. [PMID: 21808281 DOI: 10.1038/nrneph.2011.93] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Encapsulating peritoneal sclerosis (EPS) is a severe complication of long-term peritoneal dialysis (PD) with a 50% mortality rate. EPS is characterized by progressive and excessive fibrotic thickening of the peritoneum, leading to encapsulation of the bowels and intestinal obstruction. At present, EPS cannot be detected with certainty during its early stages; however, a progressive loss of ultrafiltration capacity often precedes its development. Studies that attempted to elucidate the pathogenesis of EPS have shown that the duration of exposure to PD fluids is the most important risk factor for EPS, and that young age and possibly the effects of peritonitis are additional contributory factors. The pathophysiology of EPS is probably best described as a multiple-hit process with a central role for transforming growth factor β. A form of EPS that develops shortly after kidney transplantation has also been recognized as a distinct clinical entity, and may be a common form of EPS in countries with a high transplantation rate. Criteria have been developed to identify EPS by abdominal CT scan at the symptomatic stage, but further clinical research is needed to identify early EPS in asymptomatic patients, to clarify additional risk factors for EPS and to define optimal treatment strategies.
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Affiliation(s)
- Mario R Korte
- Albert Schweitzer Hospital, Department of Internal Medicine, PO Box 444, 3300 AK Dordrecht, The Netherlands.
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Braun N, Alscher MD, Kimmel M, Amann K, Büttner M. Encapsulating peritoneal sclerosis – an overview. Nephrol Ther 2011; 7:162-71. [DOI: 10.1016/j.nephro.2010.12.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2010] [Accepted: 12/28/2010] [Indexed: 12/21/2022]
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Korte MR, Sampimon DE, Lingsma HF, Fieren MW, Looman CW, Zietse R, Weimar W, Betjes MG, Boer W, van den Dorpel M, van Ittersum RF, Konings C, Krediet R, de Sevaux R, Zanen A. Risk Factors Associated with Encapsulating Peritoneal Sclerosis in Dutch Eps Study. Perit Dial Int 2011; 31:269-78. [DOI: 10.3747/pdi.2010.00167] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective Encapsulating peritoneal sclerosis (EPS) is a serious complication of peritoneal dialysis (PD) with a multifactorial pathophysiology and possible increasing incidence. The aim of the present study was to evaluate the independent associations of PD duration, age, dialysis fluids, and kidney transplantation with EPS. Methods A multicenter case–control study was performed in the Netherlands from 1 January 1996 until 1 July 2007. The population comprised 63 patients with EPS and 126 control patients. Control patients were selected from the national registry and were matched for date of PD start. Associations were analyzed using a log linear regression model. Primary outcome was appearance of EPS. Results Compared with control patients, patients with EPS were younger at the start of PD (34.7 ± 15.4 years vs. 51.5 ± 14.7 years, p < 0.0001). The cumulative period on PD was longer in EPS patients than in control patients (78.7 ± 37.8 months vs. 32.8 ± 24 months, p < 0.0001), and the cumulative period on icodextrin was also longer in EPS patients (32.7 ± 23.3 months vs. 18.1 ± 15.7 months, p = 0.006). Compared with control patients, more EPS patients underwent kidney transplantation (47 vs. 59, p < 0.0001). With regard to the period after transplantation, the yearly probability of EPS increased in the year after transplantation to 7.5% from 1.75%. In multivariate regression analysis, cumulative PD duration, age at PD start, transplantation, time from last transplantation to EPS, calendar time, time on icodextrin, and ultrafiltration failure were independently associated with EPS. Transfer from PD to hemodialysis for reasons other than suspected EPS could not be identified as a risk factor for EPS. Conclusions Duration of PD, age at PD start, kidney transplantation, time since last transplantation, ultrafiltration failure, and time on icodextrin were associated with a higher risk of EPS.
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Affiliation(s)
- Mario R. Korte
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht
- Department of Nephrology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Denise E. Sampimon
- Department of Nephrology, Academic Medical Center, University of Amsterdam, Amsterdam
| | | | - Marien W. Fieren
- Department of Nephrology, Erasmus Medical Center, Rotterdam, Netherlands
| | | | - Robert Zietse
- Department of Nephrology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Willem Weimar
- Department of Nephrology, Erasmus Medical Center, Rotterdam, Netherlands
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- Deventer Hospital, Deventer, Netherlands
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Gayomali C, Hussein U, Cameron SF, Protopapas Z, Finkelstein FO. Incidence of Encapsulating Peritoneal Sclerosis: A Single-Center Experience with Long-Term Peritoneal Dialysis in the United States. Perit Dial Int 2011; 31:279-86. [DOI: 10.3747/pdi.2010.00196] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Encapsulating peritoneal sclerosis (EPS) is a serious complication of long-term peritoneal dialysis (PD). The reported incidence varies between 0.5% and 4.4% and increases with length of time on PD. Very few data are available on the epidemiology of EPS in the United States. The aim of the present study was assess the incidence of EPS in a single center in New Haven, Connecticut. In a retrospective analysis of all patients maintained on PD for 5 or more years, clinical symptoms were documented, abdominal computed tomography (CT) findings were reviewed, and surgical and pathology findings were noted. Patients were tracked whether they remained on PD, transferred to hemodialysis (HD), underwent transplantation, or died. Among the 76 patients that met the inclusion criteria (mean dialysis duration: 81.5 ± 22 months), 14 (18%) developed clinical symptoms (persisting for 3 or more months) suggestive of EPS. Abdominal CT imaging was done in 38 patients; 25 had radiologic features consistent with EPS. At laparotomy, 6 of 7 patients had gross findings consistent with EPS. Eleven patients met the 2000 criteria of the International Society for Peritoneal Dialysis for a diagnosis of EPS; they had clinical features, plus either radiologic or histopathologic confirmation. In 3 patients with clinical symptoms, the radiologic or surgical findings did not support a diagnosis of EPS. Of the 11 patients meeting the EPS criteria, 1 remains on PD and is doing well, 2 were transferred to HD and are doing well, 2 died as a result of EPS complications, and 6 died of other causes. The present study suggests that, in patients maintained on PD for 5 or more years at our center, the incidence of EPS is 14%. Those findings suggest that EPS may be under-recognized in the United States and that a high index of suspicion is warranted in patients maintained on PD for 5 or more years.
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Affiliation(s)
- Charina Gayomali
- Hospital of St. Raphael, Yale University, New Haven, Connecticut, USA
| | - Usama Hussein
- Hospital of St. Raphael, Yale University, New Haven, Connecticut, USA
| | - Scott F. Cameron
- Hospital of St. Raphael, Yale University, New Haven, Connecticut, USA
| | - Zenon Protopapas
- Hospital of St. Raphael, Yale University, New Haven, Connecticut, USA
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Aoki S, Makino J, Nagashima A, Takezawa T, Nomoto N, Uchihashi K, Matsunobu A, Sanai T, Sugihara H, Toda S. Fluid flow stress affects peritoneal cell kinetics: possible pathogenesis of peritoneal fibrosis. Perit Dial Int 2011; 31:466-76. [PMID: 21532005 DOI: 10.3747/pdi.2010.00157] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Peritoneal fibrosis is an essential precursor condition to the development of encapsulating peritoneal sclerosis (EPS). This serious complication leads to a high mortality rate in peritoneal dialysis (PD) patients. Although several factors, including highly concentrated glucose in the dialysis solution, are believed to be potent agents for peritoneal fibrosis, the underlying mechanism remains unclear. During PD, the dialysis solution continuously generates fluid flow stress to the peritoneum under peristalsis and body motion. Fluid flow stress has been implicated as playing a critical role in the physiologic responses of many cell types. We therefore hypothesized that fluid flow stress may be involved in the pathogenesis of peritoneal fibrosis leading to EPS. METHODS To generate fluid flow stress, culture containers were placed on a rotatory shaker in a thermostatic chamber. In this system, the shaker rotated at a speed of 25 rpm with a radius of 1.5 cm. Mesothelial cells were cultured in low-glucose (1000 mg/L) or high-glucose (4500 mg/L) complete medium with and without flow stress. RESULTS Fluid flow stress promoted hyperplasia and epithelial-mesenchymal transition (EMT) of mesothelial cells independent of glucose concentration. Fluid flow stress inhibited expression of ERK (extracellular signal-regulated kinase) and p38 MAPK (mitogen-activated protein kinase) in mesothelial cells. Administration of ERK and p38 MAPK inhibitors replicated the stress-induced morphology of mesothelial cells. CONCLUSIONS The present data indicate that fluid flow stress promotes hyperplasia and EMT of mesothelial cells via the MAPK axis, suggesting that fluid flow stress may be involved in the pathogenesis of peritoneal fibrosis.
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Affiliation(s)
- Shigehisa Aoki
- Department of Pathology and Microbiology, Faculty of Medicine, Saga University, Saga, Japan.
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Braun N, Fritz P, Biegger D, Kimmel M, Reimold F, Ulmer C, Alscher MD. Difference in the expression of hormone receptors and fibrotic markers in the human peritoneum--implications for therapeutic targets to prevent encapsulating peritoneal sclerosis. Perit Dial Int 2011; 31:291-300. [PMID: 21454390 DOI: 10.3747/pdi.2010.00118] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Encapsulating peritoneal sclerosis (EPS) is a rare but life-threatening complication of peritoneal dialysis (PD). The optimal management of patients with EPS is uncertain. In the present study, we investigated differences in the expression of nuclear receptors [progesterone (PR), androgen (AR), vitamin D (VDR), and glucocorticoid (GCR)] in the human peritoneum. We also investigated estrogen receptor (ER), matrix metalloproteinase 9 (MMP9), and transforming growth factor β1 (TGFβ1) in the context of their potential role in tamoxifen therapy. METHODS We analyzed clinical and histologic characteristics of 72 peritoneal biopsy specimens (22 from EPS patients, 11 from PD patients, 15 from uremic patients, and 24 from control subjects undergoing hernia repair). For immunophenotyping, we used antibodies against VDR, GCR, ER, PR, AR, MMP9, and TGFβ1. RESULTS In human peritoneum, VDR and GCR are highly expressed (98.6% and 87.3% respectively). Except in the case of VDR (p = 0.0012), we observed no significant difference in receptor expression between the groups. Expression of ER and PR was sparse (11.4% and 31% respectively), with higher expression in women, and AR was absent. Minimal MMP9 expression and moderate TGFβ1 expression were observed in all groups. The differences between the groups were nonsignificant. CONCLUSIONS Nuclear receptors are present in human peritoneum. Except in the case of VDR, the pattern for any one group is nonspecific. Glucocorticoids, vitamin D, and angiotensin converting-enzyme inhibitors or angiotensin II receptor blockers (via the vitamin D/angiotensin II pathway) might be suitable interventions for preservation of the integrity of the peritoneal membrane. The mechanism of action of tamoxifen is still not elucidated, ER expression in the peritoneum is sparse, and data about the studied pathways (MMP9, TGFβ) are inconsistent.
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Affiliation(s)
- Niko Braun
- Division of General Internal Medicine and Nephrology, Department of Internal Medicine, Robert-Bosch-Hospital, Stuttgart, Germany.
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Jarvis EM, Hawley CM, McDonald SP, Brown FG, Rosman JB, Wiggins KJ, Bannister KM, Johnson DW. Predictors, treatment, and outcomes of non-Pseudomonas Gram-negative peritonitis. Kidney Int 2010; 78:408-14. [DOI: 10.1038/ki.2010.149] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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