Acute-onset, steroid-sensitive, encapsulating peritoneal sclerosis in a renal transplant recipient

Posttransplant Encapsulating Peritoneal Sclerosis: A Worrying New Trend?

Encapsulating peritoneal sclerosis (EPS) is a rare but serious complication in patients on peritoneal dialysis (PD). We describe a cluster of 13 EPS cases occurring in 2 university hospitals in The Netherlands. Most of these cases were diagnosed after recent kidney transplantation, when the patients developed severe symptoms of bowel obstruction. This accumulation raised the question as to whether other than known risk factors, such as duration of PD treatment, could be involved in the development or course of EPS after transplantation. According to various publications, EPS has been diagnosed often after withdrawal from PD, suggesting that cessation in itself may be a risk factor. In addition, transplantation-related management should be considered to play a role, including the use of the profibrotic calcineurin inhibitors and the trend to reduce the load of corticosteroids in treatment regimes. To identify risk factors, further multicenter studies are required, paying special attention to alterations in immunosuppressive treatment regimens as well as PD prescriptions, including PD fluid characteristics. Transfer from PD to hemodialysis should be under serious consideration in patients eligible for kidney transplantation as soon as there are indications of ultrafiltration failure.

Encapsulating Peritoneal Sclerosis: Pathophysiology and Current Treatment Options

Encapsulating peritoneal sclerosis (EPS) is a life-threatening complication of long-term peritoneal dialysis (PD), which may even occur after patients have switched to hemodialysis (HD) or undergone kidney transplantation. The incidence of EPS varies across the globe and increases with PD vintage. Causative factors are the chronic exposure to bioincompatible PD solutions, which cause long-term modifications of the peritoneum, a high peritoneal transporter status involving high glucose concentrations, peritonitis episodes, and smoldering peritoneal inflammation. Additional potential causes are predisposing genetic factors and some medications. Clinical symptoms comprise signs of intestinal obstruction and a high peritoneal transporter status with incipient ultrafiltration failure. In radiological, macro-, and microscopic studies, a massively fibrotic and calcified peritoneum enclosed the intestine and parietal wall in such cases. Empirical treatments commonly used are corticosteroids and tamoxifen, which has fibrinolytic properties. Immunosuppressants like azathioprine, mycophenolate mofetil, or mTOR inhibitors may also help with reducing inflammation, fibrin deposition, and collagen synthesis and maturation. In animal studies, N-acetylcysteine, colchicine, rosiglitazone, thalidomide, and renin-angiotensin system (RAS) inhibitors yielded promising results. Surgical treatment has mainly been performed in severe cases of intestinal obstruction, with varying results. Mortality rates are still 25–55% in adults and about 14% in children. To reduce the incidence of EPS and improve the outcome of this devastating complication of chronic PD, vigorous consideration of the risk factors, early diagnosis, and timely discontinuation of PD and therapeutic interventions are mandatory, even though these are merely based on empirical evidence.

Should End-of-Life Preferences Be Discussed Routinely before High-Risk Surgery?

Encapsulating peritoneal sclerosis (EPS) is a rare but devastating complication of peritoneal dialysis. It is characterized by peritoneal neovascularization, fibrosis, and calcification ultimately leading to intestinal obstruction and eventual failure. Surgery for EPS has a mortality approaching 50% and most patients require some form of postoperative life-sustaining therapy (LST) during their admission. A 43-year-old gentleman with progressive EPS and significant comorbidities was assessed for enterolysis after a failed first attempt at another center. Because of his comorbidities, postoperative mortality was quoted above 50%. The patient favored surgery to improve his survival and quality of life, but was reluctant to receive prolonged LST in the event of failure of surgical therapy. The surgical team, in conjunction with a palliative care physician, therefore held extensive discussions with the patient and his partner regarding LST and its limitations. Clinical parameters to trigger a transition to palliative care were identified and agreed. Limitations on LST that are directly expressed by patients can represent a contraindication to surgery for many surgeons. Surgical Buy-In is a concept described as a perceived contract, or covenant, between the patient and clinician regarding implied consent for postoperative LST. Currently, preoperative discussions regarding limitations of LST are infrequent, and there can be reticence among patients and surgeons to have these conversations, leading to dissatisfaction on behalf of the patient and their family. After the Montgomery legal ruling, the provision and perception of informed consent are particularly pertinent. The palliative care physician is uniquely placed to contribute to such discussions as part of the surgical multidisciplinary team.

Absence of Post-Transplantation Encapsulating Peritoneal Sclerosis after Relatively Short Exposure to Peritoneal Dialysis: Prospective Analysis Using Repeated Abdominal CT Scanning

BACKGROUND

Encapsulating peritoneal sclerosis (EPS) is the most severe complication of peritoneal dialysis (PD). Several retrospective reports published between 2007 and 2009 have suggested an increasing incidence of EPS occurring after kidney transplantation. We conducted a prospective observational study to determine the incidence of post-transplantation EPS and identify possible risk factors.

METHODS

Consecutive PD patients undergoing kidney transplantation between 2009 and 2013 were included. Encapsulating peritoneal sclerosis was defined as gastrointestinal obstruction combined with radiological evidence of EPS. Gastrointestinal symptoms were assessed using a self-administered Gastrointestinal Symptom Rating Scale (GSRS) questionnaire. Abdominal computed tomography (CT) was performed prospectively at 6 and 18 months post-transplantation. The primary end point was EPS during follow-up.

RESULTS

Fifty-three PD patients were included (age 51 ± 14 years). Mean PD duration was 31.3 months. Peritoneal dialysis solutions low in glucose degradation products and icodextrin were used by 86.8% of patients. A fast or average-fast transport status was documented in 83.0%. After a median follow-up of 19 months, complete data of 47 patients were available for analysis. None of the patients developed clinical or radiological signs of EPS. The GSRS score improved from 1.87 to 1.55 (p = 0.024) and body weight increased from 75.9 to 78.3 kg (p = 0.003). Only 1 patient had new onset localized (< 20%) peritoneal thickening on CT 22 months post-transplantation.

CONCLUSION

Post-transplantation EPS did not develop in this cohort of patients with a relatively short time of PD exposure. This suggests that these patients can be transplanted safely without concern for the development of EPS, at least within the follow-up period of 19 months.

A combination of corticosteroid, sirolimus, and intradialytic parenteral nutrition in encapsulating peritoneal sclerosis: Case report and literature review

Encapsulating peritoneal sclerosis (EPS) is a rare complication of peritoneal dialysis that carries a high morbidity and mortality. Although its pathogenesis is still not clear, the "two hit theory" suggests that long term deterioration of the peritoneum combined with intraperitoneal inflammation is needed in the pathogenesis of EPS. To date, there is no proven effective therapy with an absence of randomized controlled trials. Individual case reports and small case series have reported on the use of tamoxifen and corticosteroids for medical management of EPS. Here, we present the first case of EPS treated successfully with a combination of sirolimus, low dose corticosteroid and intradialytic parenteral nutrition. A critical review of the relevant literature on this subject is also presented to determine the best approach.

A case of encapsulating peritoneal sclerosis presented shortly after renal transplantation

Encapsulating peritoneal sclerosis (EPS) is a rare but serious complication of peritoneal dialysis (PD), characterized by extensive intraperitoneal fibrosis and encasement of bowel loops. It typically associates with long-term PD and progressive loss of ultrafiltration. The management of EPS has evolved substantially from the original report of this entity and now includes immunosuppressive agents, antifibrotic agents, nutritional support, and surgical intervention. Although the exact cause of this condition remains obscure and despite the possible positive effect of immunosuppression on EPS, it has been described in the post-transplant setting upon the discontinuation of PD. We report such a case of a former PD patient who presented with EPS a month after renal transplantation. This article will highlight the current views regarding the management of post-transplant EPS and introduce the problem of long-term PD patients on the deceased-donor transplant waiting list.

Lower mortality and inflammation from post-transplantation encapsulating peritoneal sclerosis compared to the classical form

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.

Risk Factors Associated with Encapsulating Peritoneal Sclerosis in Dutch Eps Study

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.

Incidence of Encapsulating Peritoneal Sclerosis: A Single-Center Experience with Long-Term Peritoneal Dialysis in the United States

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.

Update on potential medical treatments for encapsulating peritoneal sclerosis; human and experimental data

Encapsulating peritoneal sclerosis (EPS) is an infrequent but serious complication of peritoneal dialysis (PD). The pathogenesis is unknown but speculation is ongoing. The current management of EPS focuses on prevention and treatment of the inflammatory and fibrotic changes at the level of the peritoneal membrane with immunosuppressive and antifibrotic agents, respectively. This article reviews the currently available human and animal data on potential agents to prevent and/or treat EPS. We propose a strategy for early diagnose EPS in an attempt to avoid the development of the full-blown and potentially life-threatening clinical syndrome of EPS. Future research should focus on studying potential prophylactic and therapeutic agents in humans in large, multicenter, randomized trials but also on early detection of EPS in the inflammatory phase by means of biomarkers and the establishment of a composite EPS score.

Prognosis of patients on continuous ambulatory peritoneal dialysis (CAPD) for over 10 years

BACKGROUND

Patients who have been on continuous ambulatory peritoneal dialysis (CAPD) for over 10 years are known to have a risk of developing encapsulating peritoneal sclerosis (EPS). However, the prognosis of patients on CAPD for over 10 years remains unclear.

METHODS

To better understand the efficacy of a variety of treatments for EPS, we retrospectively reviewed 25 patients who started CAPD at Toranomon Hospital from 1981 to 1997 and continued it for longer than 10 years.

RESULTS

The CAPD catheter was removed without peritoneal lavage in the initial 3 patients and they developed massive ascites. They all died of infection without resolution of the ascites. Accordingly, in the remaining 13 patients who did not undergo kidney transplantation, peritoneal lavage therapy was performed for 12 months before removing the CAPD catheter. As a result, 4 patients did not develop EPS. However, 9 patients had EPS with ascites, among whom 4 died of EPS-related diseases and 5 are alive. Five patients underwent cadaveric donor kidney transplantation. At the time of surgery, the CAPD catheter was removed without peritoneal lavage; 1 patient suffered from massive ascites immediately, although this subsided within 3 months after kidney transplantation, and 4 patients remain free from EPS-related symptoms and are doing well.

CONCLUSION

Kidney transplantation may be an option for preventing EPS. This study showed that improvement of the uremic state as well as treatment with immunosuppressants including corticosteroids may contribute to preventing EPS.

A case of CMV infection and encapsulating peritoneal sclerosis in a renal transplant recipient

Encapsulating peritoneal sclerosis (EPS) is a rare but severe complication of peritoneal dialysis. It has been reported that the condition of patients with EPS may improve after renal transplantation. However, there are also several reports of EPS occurring after renal transplantation. In this report, we present a patient who developed EPS combined with gastrointestinal cytomegalovirus infection 21 months after successful renal transplantation, despite the use of tacrolimus and low-dose steroid as maintenance immunosuppression.

Encapsulating peritoneal sclerosis: experience of a tertiary referral center

AIM

Encapsulating peritoneal sclerosis (EPS) is arguably the most serious complication of chronic peritoneal dialysis (PD) therapy with extremely high mortality rates. We aimed to establish the rates of EPS and factors associated with its development in a single center.

METHODS

We retrospectively reviewed the records of all our PD patients from 1 January 1989 until 31 December 2008. All suspected cases were confirmed at laparotomy. Multifactorial models adjusted for potentially confounding variables such as age and sex.

RESULTS

Eleven cases of EPS were identified giving a prevalence rate of 1.98%. Median duration on PD was substantially longer in affected versus unaffected patients (42.5 months versus 13.8 months; p = 0.0002). EPS patients had experienced a mean of 3.54 previous cases of peritonitis (1 infection per year versus 0.71 per year in unaffected patients; p = 0.075). Six patients died (54.5%) due to intra-abdominal sepsis including all five who presented with small bowel obstruction. Three patients had an omentectomy and adhesiolysis performed with a successful outcome.

CONCLUSION

Our study reinforces the link between duration on PD and EPS. While mortality was high in our cohort, emerging surgical techniques demonstrate a favorable outcome that can be achieved even in severely affected cases.

Tamoxifen is associated with lower mortality of encapsulating peritoneal sclerosis: results of the Dutch Multicentre EPS Study

BACKGROUND

Encapsulating peritoneal sclerosis (EPS) is a serious complication of peritoneal dialysis (PD) with an increasing incidence. There is no clear consensus on the treatment of EPS, but anecdotal reports indicate improvement in EPS patients treated with tamoxifen. At present, there is no evidence for the effect of tamoxifen treatment in EPS patients. This study investigates the effect of treatment with tamoxifen on survival in EPS patients.

METHODS

This study is a retrospective analysis of survival in EPS patients as part of the Dutch multicentre EPS study in the period January 1996 to July 2007. Sixty-three patients with severe EPS were followed up until August 2008. Demographic, patient and PD-related variables of EPS patients were investigated. Patients treated with tamoxifen were compared to patients not treated with tamoxifen. Survival was analysed with multivariate Cox regression analysis.

RESULTS

Twenty-four patients were treated with tamoxifen, and 39 were not treated with tamoxifen. The clinical and demographic characteristics were similar for the tamoxifen-treated and non-treated groups. The mortality rate was significantly lower in tamoxifen-treated patients compared to EPS patients not treated with tamoxifen (45.8% vs 74.4%, P=0.03). Survival in tamoxifen-treated patients, adjusted for calendar time, age, use of corticosteroids, presence of functioning transplantation, use of parental nutrition and centre influences was longer in comparison to not-treated patients (HR 0.39, P=0.056).

CONCLUSIONS

Tamoxifen treatment in EPS patients is associated with lower mortality and shows a trend to an increased multivariate-adjusted survival. This supports additional use of tamoxifen to treat patients with severe EPS.

Encapsulating Peritoneal Sclerosis—Medical and Surgical Treatment

Encapsulating peritoneal sclerosis (EPS) is a rare but devastating complication. The patients at high risk for EPS include those on peritoneal dialysis (PD) for more than 8 – 10 years and patients with high peritoneal transport and frequent peritonitis. Effective medical treatment with tamoxifen and immunosuppressives (a steroid with or without azathioprine or mycophenolate) has been reported. Surgical enterolysis is needed when irreversible intestinal obstruction occurs. In experienced hands, mortality can be reduced to a few percentage points, but the recurrence rate is very high. Noble plication has been reported to reduce the recurrence rate. Accelerated EPS development may possibly occur after conversion from PD to HD.

Pathogenesis and Treatment of Encapsulating Peritoneal Sclerosis: Basic and Translational Research

Encapsulating peritoneal sclerosis is a devastating condition in long-term peritoneal dialysis patients. Animal models have employed chemical insults to simulate its pathology and have provided insights into its pathophysiology, which appears to include inflammation, angiogenesis, and fibrosis. Monitoring of biomarkers and interruption of molecular pathways have provided potential interventions to slow or prevent the disease process. However, there remain many questions concerning the trigger that alters chronic peritoneal inflammation in peritoneal dialysis to severe sclerosis, peritoneal adhesions, and bowel obstruction. Further advances in therapy will likely require an effective means of an early diagnosis through related biomarkers, which in turn will require further advances in the understanding of the pathogenesis of this disease process.