Incidence Of Encapsulating Peritoneal Sclerosis Research Articles

Inkapsulirajuća peritoneumska skleroza - retka i ozbiljna komplikacija peritoneumske dijalize - prikaz slučaja

Introduction: End-stage renal disease is a terminal illness with a glomerular filtration rate of less than 15 mL/min. when must start one of the methods of renal replacement therapy: hemodialysis, peritoneal dialysis or kidney transplantation. Peritoneal dialysis is based on the processes of diffusion and osmosis, while the transport of substances takes place through the peritoneal membrane. The advantages of peritoneal dialysis compared to hemodialysis include longer-term preservation of residual renal function, preservation of blood vessels and a better quality of life for the patient. Complications of peritoneal dialysis can be infectious, metabolic and mechanical. Encapsulating peritoneal sclerosis (EPS) is a life-threatening complication of peritoneal dialysis (PD) treatment. The incidence of EPS is variable between 0.7 and 3.7%, while it increases with the length of PD treatment (0.7-6.4% after 5 years to as much as 17.2% after 15 years). The diagnosis of EPS is based on clinical symptoms. and signs as well as specific, but not pathognomonic, radiological and pathohistological findings. Features of IPS on computed tomography (CT) images are thickening and calcification of the peritoneal membrane, thickening of the intestinal wall, narrowing and dilatation of the in-testine, as well as "trapped" fluid collections. Case report: A 60-year-old patient, who has been treated with peritoneal dialysis for 4 years, was hospitalized due to severe gastrointestinal complaints. Due to clinical findings a peritoneal equilibration test was performed, which determined that it was a moderately fast transporter. Based on the findings of the computed tomography, the diagnosis was confirmed. Treatment is started tamoxifen and prednisone was started, the response to therapy was positive. Despite the control of sclerosing peritonitis, death occurred because of cardiac decompensation. Conclusion: Early diagnosis is necessary to start specific treatment in a timely manner and, if possible, preserve peritoneal dialysis as a treatment method and patient survival.

Encapsulating Peritoneal Sclerosis and Mortality Related to Infection in Patients on Combination Once-Weekly Hemodialysis with Peritoneal Dialysis

Introduction: Previous studies showed that the combination of peritoneal dialysis (PD) and once-weekly hemodialysis is associated with lower all-cause and cardiovascular mortality. This study aimed to compare the incidence of encapsulating peritoneal sclerosis (EPS) and infection-related mortality among those on combination therapy and those on PD alone. Methods: This prospective study on the Japanese Renal Data Registry included patients on PD from 2010 to 2014. Subjects were followed up until the end of 2015. Exposure of interest was combination therapy compared with PD alone. Patients who transitioned to combination therapy were matched with those on PD alone by propensity scores. Outcomes were EPS and infection-related mortality. Data were analyzed using Cox regression models. Results: Among the matched cohort, 608 and 869 patients were on combination therapy and on PD alone, respectively. Dialysate-to-plasma creatinine (D/P Cr) ratio decreased over time among those on combination therapy, while the ratio increased among those on PD alone (p = 0.01 by the mixed-effects model). During a median follow-up of 2.5 years, 33 experienced EPS and 55 died of infection. Combination therapy was associated with lower infection-related mortality (HR [95% CI]: 0.52 [0.28–0.95]) but not with EPS (HR: 1.21 [0.61–2.40]). Lower mortality was not limited to intra-abdominal infection but also observed for pulmonary infection. Sensitivity analyses considering the effects of dialysis facilities yielded similar results. Conclusions: Combination therapy was associated with lower infection-related mortality. It was also associated with a decline in the D/P Cr ratio over time but not with lower incidence of EPS during the short observation period.

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.

Incidence and outcomes of encapsulating peritoneal sclerosis (EPS) and factors associated with severe EPS.

BackgroundEncapsulating peritoneal sclerosis (EPS) is a rare but serious complication of long-term peritoneal dialysis (PD). However, previous studies reported large variations in its mortality rates that may associate with a different degree of EPS severity. This study reports the incidence and outcomes of EPS and identifies the risk factors associated with severe EPS.MethodsWe retrospectively analyzed clinical data of EPS patients from 3 medical centers in Taiwan from January 1982 to September 2015, and classified patients as having mild/moderate or severe EPS. Patients with intractable intestinal obstruction/gut-related sepsis that needed surgical intervention or resulted in mortality were in severe EPS group. Follow-up for outcome was through December 31, 2015. Clinical characteristics, peritoneal dialysis (PD)-related parameters, biochemical and imaging results were analyzed and compared between groups.ResultsFifty-eight of 3202 patients undergoing PD during the study period had EPS (prevalence 1.8%). The incidence of EPS increased for patients on PD for >6–8 years (≤6 yrs. vs. >6–8 yrs., 0.0% vs. 1.8%, p = 0.001). Relative to those on PD for >6–8 years, the risk of EPS significantly increased with PD duration longer than 10 years (>10–12 years vs. >6–8 years: OR: 5.5, 95% CI: 1.7–17.1, p < 0.01). Twenty-three patients fulfilled the criteria for severe EPS. The overall mortality rate of EPS was 35% (20/58), and was 74% (17/23) in the severe EPS group. The average serum levels of C-reactive protein (CRP) and intact-parathyroid hormone (i-PTH), which were checked every 3~6 months within one year before diagnosis of EPS, were higher in severe EPS group than in mild/moderate group (p = 0.02, p = 0.08, respectively). Multivariate analysis revealed severe EPS was independently associated with bowel tethering (based on CT), presentation with bloody ascites, diagnosis of EPS after withdrawal from PD, and i-PTH ≥ 384 pg/mL. Receiver operating characteristic analysis indicated that presentation with 2 or more of the 5 risk factors (EPS diagnosis after PD withdrawal, bloody ascites, bowel tethering, CRP ≥ 29 mg/L, and i-PTH ≥ 384 pg/mL) had a good accuracy (AUC = 0.80, p = 0.001) for prediction of severe EPS.ConclusionsThe incidence of EPS increases with PD duration. Severe EPS has high mortality rate and is associated with bowel tethering, presentation of bloody ascites, diagnosis after PD withdrawal, and higher serum levels of i-PTH before EPS diagnosis. Having 2 or more of the 5 risk factors can provide a good accuracy for prediction of severe EPS.

Eosinophilic Inflammation in Peritoneal Fibrosis Patients Undergoing Peritoneal Dialysis.

Renal replacement therapy is vital for patients with chronic renal failure. Each type of renal replacement therapy has its own characteristics, and patients select it according on their living environment or conception of quality of life. Under the recent medical environment in Japan, economic burden of dialysis is another concern. For patients with chronic renal failure, the outcome of dialysis is vital. How to prevent or control side effects and complications is also important. One type of dialysis treatment is called peritoneal dialysis. Complications from long-term peritoneal dialysis include encapsulating peritoneal sclerosis (EPS), which can lead to life-threatening intestinal obstruction. Here, we hope to prevent the incidence of EPS through examining new possibilities in the pathogenesis during peritoneal dialysis and considering countermeasures. Membrane dialysis is a treatment methodology that makes use of the semipermeable function of body membranes. When the composition of the peritoneal dialysate is adjusted, it also removes waste products and adjusts water level. Chemical stimuli of peritoneal dialysate on peritonea can trigger inflammation and, when long-lasting, the latter is considered to cause EPS. For the body, chemical stimuli are invasive. Damaged body tissues have a capacity to repair themselves. The innate immune system is known to work in response to nonspecific stimulation, and so it is well conceivable that it is active in the abdominal cavity under peritoneal dialysis. Among many inflammatory cells involved in the innate immune system, we focus on the role of eosinophils to consider the possibility of unknown pathogenesis. Key Messages: Eosinophilic inflammation may cause EPS.

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

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. 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. 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. 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.

Significant Decreasing Incidence of Encapsulating Peritoneal Sclerosis in the Dutch Population of Peritoneal Dialysis Patients

The Dutch Encapsulating Peritoneal Sclerosis (EPS) Registry was started in 2009. Cases were identified by contacting all Dutch nephrologists twice yearly. The predefined criteria for EPS allowed for inclusion of patients with diagnosed and suspected EPS. Cases registered between January 2009 and January 2015 were analyzed with follow-up until September 2015. Fifty-three EPS cases were identified, of which 28.3% were post-transplantation EPS cases. Fourteen patients were initially categorized as suspected EPS, of whom 13 developed EPS. A remarkable 6-fold decrease in the yearly incidence of EPS was observed, from 0.85% in 2009 to 0.14% in 2014. This decrease could not be explained by a decrease in the number of PD patients or average duration of PD treatment in this period. Two-year survival of EPS patients was 52%. The use of tamoxifen and surgical interventions increased significantly over the years. Tamoxifen-treated cases showed a trend to better patient survival and post-transplantation EPS had a significantly favorable outcome. In conclusion, the incidence of EPS has declined significantly in the Netherlands from 2009 to 2014.

Risk factors of severe peritoneal sclerosis in chronic peritoneal dialysis patients

Peritoneal dialysis (PD) offers the healthiest way for starting renal replacement therapy (RRT) in End Stage Renal Disease patients, however exposes long-term PD patients to a dangerous complication named encapsulating peritoneal sclerosis (EPS). In this study, we searched for possible risk factors of EPS. Data were collected from two PD centers covering period 1995–2012 and comprised 464 patients. Control group defined as PD patients stayed on PD >42 month (n = 122), and case group was 12 confirmed EPS patients. Associations were analyzed using linear regression analysis. Prevalence and incidence of EPS were 2.59% and 8.9% with an incidence of 0.7% patient-years, respectively. The age at start of PD in EPS patients (32.75 ± 10.8 year) was significantly lower compared with control group (49.61 ± 16.18 year, p = .0001). The mean duration of PD in EPS and control group were 2494.4 ± 940.9 and 1890.2 ± 598.8 days (p = .002). Control group had 145 episodes of peritonitis during total duration of 7686 patient months (peritonitis rate of 1/53). This was 1/26 with a total 38 episodes of peritonitis during the total duration of 997 patient months (p = .01) for EPS group. In regression analysis, PD duration, age at PD start and duration of Ultrafiltration failure (UFF) were associated with EPS. Longer time being on PD, younger age, and higher UFF duration were the risk factors for EPS development.

Incidence and outcome of encapsulating peritoneal sclerosis.

BackgroundStudies report variation in the incidence and outcomes of encapsulating peritoneal sclerosis (EPS). This study reports the incidence and outcome of EPS cases in a national cohort of peritoneal dialysis (PD) patients.MethodsThe incident cohort of adult patients who started PD between 1 January 2000 and 31 December 2007 in Scotland (n = 1238) was identified from the Scottish Renal Registry. All renal units in Scotland identified potential EPS cases diagnosed from 1 January 2000 to 31 December 2014, by which point all patients had a minimum of 7 years follow-up from start of PD.ResultsBy 31 December 2014, 35 EPS cases were diagnosed in the 1238 patient cohort: an overall incidence of 2.8%. The incidence for subgroups with longer PD duration rises exponentially: 1.1% by 1 year, 3.4% by 3 years, 8.8% at 4 years, 9.4% at 5 years and 22.2% by 7 years. Outcomes are poor with mortality of 57.1% by 1 year after diagnosis. Survival analysis demonstrates an initial above-average survival in patients who later develop EPS, which plummets to well below average after EPS diagnosis.ConclusionsThe incidence of EPS is reassuringly low provided PD exposure is not prolonged and this supports ongoing use of PD. However, continuing PD beyond 3 years results in an exponential rise in the risk of developing EPS and deciding whether this risk is acceptable should be made on an individual patient basis.

Encapsulating peritoneal sclerosis-a rare but devastating peritoneal disease.

Encapsulating peritoneal sclerosis (EPS) is a devastating but, fortunately, rare complication of long-term peritoneal dialysis. The disease is associated with extensive thickening and fibrosis of the peritoneum resulting in the formation of a fibrous cocoon encapsulating the bowel leading to intestinal obstruction. The incidence of EPS ranges between 0.7 and 3.3% and increases with duration of peritoneal dialysis therapy. Dialysis fluid is hyperosmotic, hyperglycemic, and acidic causing chronic injury and inflammation in the peritoneum with loss of mesothelium and extensive tissue fibrosis. The pathogenesis of EPS, however, still remains uncertain, although a widely accepted hypothesis is the “two-hit theory,” where, the first hit is chronic peritoneal membrane injury from long standing peritoneal dialysis followed by a second hit such as an episode of peritonitis, genetic predisposition and/or acute cessation of peritoneal dialysis, leading to EPS. Recently, EPS has been reported in patients shortly after transplantation suggesting that this procedure may also act as a possible second insult. The process of epithelial–mesenchymal transition of mesothelial cells is proposed to play a central role in the development of peritoneal sclerosis, a common characteristic of patients on dialysis, however, its importance in EPS is less clear. There is no established treatment for EPS although evidence from small case studies suggests that corticosteroids and tamoxifen may be beneficial. Nutritional support is essential and surgical intervention (peritonectomy and enterolysis) is recommended in later stages to relieve bowel obstruction.

Can EPS Development be Avoided with Early Interventions? The Potential Role of Tamoxifen—A Single-Center Study

Encapsulating peritoneal sclerosis (EPS) is a severe complication of peritoneal dialysis (PD). Identification of patients at high risk for EPS ("EPS-prone") and delivery of appropriate interventions might prevent its development. Our aim was to evaluate the clinical characteristics and outcomes of all EPS and EPS-prone patients diagnosed at our PD unit. For a 30-year period representing our entire PD experience, we retrospectively identified all patients with EPS (diagnosed according to International Society for Peritoneal Dialysis criteria) and all patients defined as EPS-prone because they met at least 2 established criteria (severe peritonitis, PD vintage greater than 3 years, severe hemoperitoneum, overexposure to glucose, and acquired ultrafiltration failure). Of 679 PD patients, we identified 20 with EPS, for an overall prevalence of 2.9%. Mean age at diagnosis was 50.2 ± 16.4 years, with a median PD time of 77.96 months (range: 44.36 - 102.7 months) and a median follow-up of 30.91 months (range: 4.6 - 68.75 months). Of patients with EPS, 10 (50%) received tamoxifen, 10 (50%) received parenteral nutrition, and 2 (10%) underwent adhesiolysis, with 25% mortality related to EPS. Another 14 patients were identified as EPS-prone. Median follow-up was 54.05 months (range: 11.9 - 87.04 months). All received tamoxifen, and 5 (36%) received corticosteroids; none progressed to full EPS. We observed no differences in baseline data between the groups, but the group with EPS had been on PD longer (84 ± 53 months vs 39 ± 20 months, p = 0.002) and had a higher cumulative number of days of peritoneal inflammation from peritonitis (17.2 ± 11.1 days vs 9.8 ± 7.9 days, p = 0.015). Overall mortality was similar in the groups. The incidence of EPS declined during our three decades of experience (5.6%, 3.9%, and 0.3%). Being a serious, life-threatening complication of PD, EPS requires high suspicion to allow for prompt diagnosis and treatment. Early detection of EPS-prone states and delivery of appropriate intervention might prevent EPS development. Tamoxifen seems to be a key strategy in prevention, but caution should be used in interpreting our results. Additional randomized controlled studies are needed.

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 underrecognized in the United States and that a high index of suspicion is warranted in patients maintained on PD for 5 or more years.

The Role of Peritoneal Lavage and the Prognostic Significance of Mesothelial Cell Area in Preventing Encapsulating Peritoneal Sclerosis

Severe peritoneal injury and encapsulating peritoneal sclerosis (EPS) as complications of long-term peritoneal dialysis (PD) are issues of concern. The usefulness of peritoneal lavage after withdrawal of PD and the risk factors for EPS have not been addressed until now. Little is known about mesothelial cell area (MCA) in the effluent as a marker of peritoneal injury. In the present study, we investigated the clinical significance of peritoneal lavage after PD withdrawal and tried to clarify the risk factors related to MCA, with the aim of preventing EPS. We also developed an algorithm for the clinical management of long-term PD patients. We assigned 247 PD patients to one of two cohorts after PD withdrawal: a non-lavage group (73 patients) and a lavage group (174 patients). To clarify the risk factors, we studied these potential predictors: PD duration, dialysate-to-plasma ratio of creatinine (D/P Cr) at the time of PD withdrawal, frequency of peritoneal lavage, type of PD or lavage solution, MCA at the time of PD withdrawal ("PD area"), and MCA at the time of peritoneal lavage withdrawal or censoring ("LA area"). Recurrent intestinal obstruction was defined as the main manifestation of EPS. Diagnostic performance and cut-off values were then calculated for the selected risk factors. The overall incidence of EPS was significantly lower in the lavage group, at 6.9% (5.2% during lavage and 2.5% after lavage), than in the non-lavage group, at 15.1%. The risk factors and cut-off values were PD area (350 µm(2)) and PD duration (78 months) for the non-lavage group; and PD area (350 µm(2)) and LA area (320 µm(2)) for the lavage group. Patients with a PD duration of 78 months or more and a PD area of 350 µm(2) or more were defined as high-risk patients in the non-lavage group (risk ratio: 11.14), and patients with a PD area of 350 µm(2) or more and an LA area of 320 µm(2) or more were defined as high-risk patients in the lavage group (risk ratio: 10.43). Peritoneal lavage is effective in reducing the incidence of EPS after PD withdrawal. The PD duration and MCA are significant risk factors, and these markers are useful for classifying patients into low- and high-risk groups for the development of EPS.

No need for an “expiry date” in chronic peritoneal dialysis to prevent encapsulating peritoneal sclerosis

Encapsulating peritoneal sclerosis (EPS) is drawing attention to the PD community because of its unpredictable onset and high mortality. Recently, the Scottish Renal Registry [1] has established the incidence of EPS and its correlation with PD duration in that region. The rate of EPS among patients on PD was 1.5%, with an incidence of 4.9 per 1,000 person-years. This rate is well within those reported previously (0.7–3.3%) [2–7]. Interestingly, the EPS rate increased with longer duration of PD up to 5 years (from 0% at\1 year to 8.8% at[5 to 6 years), and then decreased (5% at[6 years). The median duration of PD before EPS developed was 5.1 years. At the time of diagnosis only 26% of patients with EPS were on PD. In the remainder (74%), EPS was diagnosed after PD had been discontinued; 50% of them were diagnosed with EPS after kidney transplantation with calcineurin inhibitor-based immunosuppression.

Development of Encapsulating Peritoneal Sclerosis Following Bacterial Peritonitis in a Peritoneal Dialysis Patient

Encapsulating peritoneal sclerosis (EPS) isan uncommon and often fatal complication inpatients on peritoneal dialysis (PD) therapy. EPSis a clinical syndrome characterized by symp-toms of impaired intestinal motility, such asanorexia, nausea, vomiting, abdominal fullness,abdominalpain,absentbowelsounds,andconsti-pation.

Encapsulating Peritoneal Sclerosis in Patients on Peritoneal Dialysis in Slovenia

Encapsulating peritoneal sclerosis (EPS) is a rare complication in patients on peritoneal dialysis (PD), the prevalence of which increases with the time spent on PD. Various causative factors have been proposed, but the pathogenesis still remains unclear. The aim of our retrospective study was to analyze the basic clinical characteristics and outcomes of five patients diagnosed with EPS out of 423 patients treated with PD between January 1983 and December 2003. One patient was admitted due to ultrafiltration failure of the peritoneal membrane, and four patients were admitted for acute peritonitis. All of our patients presented with clinical symptoms suggestive of obstructive ileus. We confirmed the diagnosis of EPS with a computer tomography scan, a diagnostic laparotomy or laparoscopy, and a biopsy of the parietal peritoneum. We treated all of our patients with catheter removal, transferal to hemodialysis, antibiotics, complete parenteral nutrition, methylprednisolone, and tamoxifen for 6 months. One patient was treated with surgical enterolysis and died of septic complications, another patient died of sudden cardiac death during treatment. Three patients were doing well for 4-7 months after the treatment was started. The incidence of EPS was 1.2% and the mortality rate was 40%. EPS is a rare complication in longstanding PD patients in our institution. Despite treatment with hemodialysis, complete parenteral nutrition, steroids, tamoxifen and surgical intervention, the mortality rate is high and comparable to other reports.

Experimental Study on Long-Term Exposure to a Biocompatible, Hypertonic, Pyruvate-Buffered Dialysis Solution

Chronic exposure to glucose and glucose degradation products (GDPs) in dialysis solutions is involved in the pathogenesis of peritoneal neoangiogenesis and fibrosis, potentially leading to encapsulating peritoneal sclerosis (EPS). High lactate concentrations may contribute to glucose toxicity by creating a state of pseudohypoxia, which stimulates the formation of various growth factors. To study the effects of long-term peritoneal exposure to a filter-sterilized pyruvate-buffered solution with a combination of 3 osmotic agents (amino acids, glycerol, glucose: PYRAGG) on peritoneal function and morphology. Rats were exposed daily for a period of 20 weeks to PYRAGG, or to a conventional heat-sterilized solution (LH), or to a filter-sterilized solution (LF), after which a peritoneal function test was done and peritoneal tissue was obtained. Peritoneal solute and fluid transport characteristics at 20 weeks were similar in all groups. Fibrosis was most pronounced in the LH group compared to the others, suggesting an effect of GDPs. A marked reduction in the number of omental vessels was noted in the PYRAGG group (59% reduction compared to LH). A modest reduction (28%) was found in the LF animals. This points to a marked effect of reduced exposure to glucose. PYRAGG was more biocompatible than a filter-sterilized glucose/lactate solution because it did not induce marked peritoneal abnormalities after long-term exposure. This did not lead to altered peritoneal transport characteristics. It is likely that further development of PYRAGG-like solutions will decrease the incidence of EPS.

Encapsulating Peritoneal Sclerosis in Japan

Encapsulating peritoneal sclerosis (EPS), the most serious and classical complication of peritoneal dialysis (PD), was recognized soon after the introduction of PD. Within a little more than a decade after PD was first introduced in Japan, the country began experiencing an increasing number of EPS cases. The present paper discusses the clinical stages of EPS, the incidence of EPS in Japan and the as-yet incompletely understood mechanisms of its development, and EPS management and prevention.

Recommendation of the Surgical Option for Treatment of Encapsulating Peritoneal Sclerosis

Encapsulating peritoneal sclerosis (EPS) is an intestinal obstruction syndrome in which peritoneal deterioration and intraperitoneal inflammation result in intestinal adhesions, which are covered with a fibrin capsule and cause bowel obstruction. The widespread use of peritoneal dialysis (PD) has been associated with an increase in the number of patients with this life-threatening complication. For this reason, some negative comments have been made about PD therapy. However, recent clinical studies have elucidated the pathogenesis of EPS and proposed therapeutic strategies. Currently, these facts are known: EPS occurs in 2.5% of all patients (3.18/1000 patient-years). A longer duration of PD is associated with a higher incidence of EPS and a poorer prognosis, indicating the involvement of peritoneal deterioration in the development of EPS. Development of EPS involves some kind of infection. Development of EPS frequently occurs after PD withdrawal and catheter removal. Peritoneal lavage after PD withdrawal delays, but cannot prevent the development of EPS. Timely administration of steroids is effective. Surgical adhesiolysis is the optimal treatment to relieve bowel obstructions, but does not exclude the potential for re-adhesions, requiring various ingenious gastro-intestinal surgical techniques.

Encapsulating Peritoneal Sclerosis: Prevention and Treatment

Since the first peritoneal dialysis (PD) patients with encapsulating peritoneal sclerosis (EPS) were reported in 1980, EPS has been considered primarily a fatal complication. The incidence of EPS in PD patients has been reported to be 2.5%, with a negative effect of increasing PD duration (which also augments mortality). Because EPS occurs after withdrawal from PD in more than half of all cases, strict monitoring is necessary when a long-term PD patient is withdrawn from PD. Maintaining patients on standard PD with conventional solutions for more than 8 years is associated with a substantial risk of EPS development. Treatment appropriate to the disease stage is most important in EPS. Basic therapeutic strategies for EPS include the appropriate use of steroids. If bowel obstruction persists, laparotomy and enterolysis should be performed to achieve a complete cure. It is now recognized that EPS need not be a fatal complication of PD.