Years Of Peritoneal Dialysis Research Articles

Sclerosing encapsulating peritonitis after peritoneal dialysis

Patients with chronic renal failure in use of peritoneal dialysis (PD) are subject to various complications of the renal replacement therapy. We report a rare complication of PD in which the peritoneum, after years of contact with hypertonic dialysate, is gradually replaced by fibrous tissue. This patient had several complications after initiation of PD including a bacterial peritonitis, tertiary hyperparathyroidism (being treated with parathyroidectomy 2) and cholelithiasis (being treated with laparoscopic cholecystectomy). After 8 years of peritoneal dialysis was transferred to hemodialysis by decreasing ultrafiltration and episodes of intestinal sub-occlusion, being diagnosed as sclerosing encapsulating peritonitis (SEP). He is currently on corticotherapy with a significant reduction of symptoms and likely stabilization of the SEP.

Encapsulating peritoneal sclerosis

Encapsulating peritoneal sclerosis (EPS) is a rare but potentially lethal complication of peritoneal dialysis (PD). Peritoneal tuberculosis is considered an etiologic factor. We report a case of EPS in a 40-year-old man who was switched to hemodialysis because of peritoneal tuberculosis after 2 years of PD. Because of the persistence of gastrointestinal symptoms and cachexia, laparoscopic exploration was performed, which revealed an important thickening of the peritoneal membrane sheathing the intestinal loops. Accordingly, a diagnosis of EPS was made. Anti-tuberculosis treatment associated with a low dose of corticosteroids stabilized the disease.

Prognostic Value of Arterial Pulse Wave Velocity in Peritoneal Dialysis Patients

Background: Cardiovascular disease is the most common cause of mortality in chronic peritoneal dialysis (PD) patients. Increased arterial stiffness may be related to a high peritoneal permeability, resulting in fluid overload of PD patients. We examined the prognostic value and factors that govern the longitudinal change of arterial pulse wave velocity (PWV) in Chinese PD patients. Method: We enrolled 155 new PD patients. PWV was measured at baseline and then repeated after 2 years of follow-up. Results: At 24 months, the survival of patients with baseline carotid-femoral (CF)-PWV above 10 m/s was significantly worse than that of those with CF-PWV below 10 m/s (76.1 vs. 88.6%, p = 0.006). However, after adjusting for confounding factors, CF-PWV was not an independent predictor of survival. Amongst the 100 patients who had repeated PWV measurement after 2 years, the average CF-PWV increased from 9.92 ± 2.04 to 11.00 ± 2.30 m/s (p < 0.0001). The change in CF-PWV over 2 years significantly correlated with systolic blood pressure (r = 0.241, p = 0.036), serum calcium level (r = 0.231, p = 0.044), and normalized protein nitrogen appearance (NPNA) (r = –0.337, p = 0.001). Conclusions: A high baseline CF-PWV was associated with a lower overall survival of Chinese PD patients, but the prognostic value of CF-PWV disappeared after adjusting for confounding factors. After 2 years of PD, most patients had progressive increase in CF-PWV; the magnitude of increase is related to systolic blood pressure, serum calcium level, and baseline NPNA. Further study is needed to determine whether serial measurement of CF-PWV provides additional prognostic information.

Risk Factors for High Dialysate Glucose use in PD Patients—A Retrospective 5-Year Cohort Study

Use of high concentrations of glucose for peritoneal dialysis (PD) may produce unfavorable results. Our previous study showed that high initial glucose load is associated with poor PD technique survival. This retrospective cohort study at a medical center in Taiwan aimed to understand the factors associated with high glucose load in long-term PD patients. We reviewed 90 newly started PD patients over 5 years. We determined glucose load by calculating annual glucose weight and dialysate volume administered. Multiple linear regression analyses with time-dependent covariates were used to determine factors that influence the annual average dialysate glucose concentration. The study group included 47 men and 43 women with a mean age of 53.4 +/- 13.9 years. Technique survival rates were 91.0%, 84.1%, and 77.6% at the beginning of the second, third, and fourth year of PD therapy respectively. The presence of diabetes mellitus (DM), high body mass index (BMI), and low weekly renal Kt/V were significantly correlated with high average dialysate glucose concentration during the first, second, and third years. For patients undergoing PD for more than 3 years, residual renal function (RRF) deteriorated, and only DM significantly affected higher dialysate glucose concentration in the fourth year. Patients with DM, high BMI, and low RRF were more likely to require a high glucose load for PD therapy, especially during the first 3 years. After those 3 years of PD, DM was the only significant factor in the need for higher glucose load. To reduce the glucose load in chronic PD patients, alternative osmotic agents such as icodextrin or amino acids should be considered in the daily PD regimen.

The time course of peritoneal transport parameters in peritoneal dialysis patients who develop encapsulating peritoneal sclerosis

Encapsulating peritoneal sclerosis (EPS) is a severe complication of peritoneal dialysis (PD). The first aim was to analyse the risk of EPS in patients who had developed ultrafiltration failure (UFF). The second aim was to identify specific peritoneal transport alterations that distinguish patients with UFF from patients who will develop EPS. All patients of this study were treated with PD between July 1995 and December 2008 in the Academic Medical Center, Amsterdam, the Netherlands. Risk analysis: all PD patients who developed UFF after at least 2 years of PD. Peritoneal transport analysis: all patients who had PD for at least 55 months were included: 12 EPS patients, 21 patients with UFF and 26 patients with normal ultrafiltration (UF). The peritoneal function was measured yearly with a standard peritoneal permeability analysis. UFF was defined as net UF < 400 mL after a 4-h dwell with a 3.86% dialysis solution. Risk analysis: Of the 48 UFF patients, 10 eventually developed EPS. Fifty percent of the patients who continued PD for more than 3 years after the establishment of UFF developed EPS. Peritoneal function analysis: No differences were present for the time courses of solute transport and fluid transport between the EPS and the UFF groups. Overall, the EPS and normal UF groups had lower values for the effective lymphatic absorption rate (ELAR) than the UFF group. The risk of EPS increases with continuation of PD while UFF is present. Transport characteristics are similar between EPS patients and UFF patients without this complication. A constantly low ELAR may distinguish the EPS patients from those with UFF only.

Peritonitis-free survival in peritoneal dialysis: an update taking competing risks into account

Peritonitis-free survival is commonly reported in the peritoneal dialysis (PD) literature. The Kaplan-Meier method appears to be the only technique used to date, although it has known limitations for cohorts with multiple outcomes, as in PD. In the presence of these 'competing risks' outcomes, the Kaplan-Meier estimate is interpretable only under restrictive assumptions. In contrast, methods which take competing risks into account provide unbiased estimates of probabilities of outcomes as actually experienced by patients. We analysed peritonitis-free survival in a cohort of 8711 incident patients from the 'Registre de Dialyse Péritonéale de Langue Française' between 1 January 2000 and 31 December 2007 by calculating the cumulative incidence (CI) of the first episode of peritonitis using the Kaplan-Meier method and a method accounting for competing risks. We compared the CI in different patient groups by the log-rank test and a test developed for competing risk data, Gray's test. After 5 years of PD, the CI of at least one peritonitis episode was 0.4, and the probability of any outcome was 0.96. The Kaplan-Meier method overestimated the CI by a large amount. Compared with the log-rank test, Gray's test led to different conclusions in three out of seven comparisons. The competing risk approach shows that the CI of at least one peritonitis episode was lower than reported by the Kaplan-Meier method but that survival peritonitis-free and still on PD was overall low. The competing risk approach provides estimates which have a clearer interpretation than Kaplan-Meier methods and could be more widely used in PD research.

Peritonealdialyse

Peritoneal dialysis (PD) is a modern kidney replacement option capable of meeting the high demands placed on the desired quality of life in a home therapy setting. Survival probability is comparable between hemodialysis (HD) and PD and some retrospective analyses have even proven lower mortality in the first years of PD. Especially diabetics benefit from PD as the initial dialysis treatment because it offers a better quality of life, better preservation of residual renal function, less electrolyte disorders, no complications due to fistulas for HD and less hypotensive periods. Higher peritoneal glucose absorption needs to be treated with equivalent insulin therapy according to the specific regimen to achieve adequate blood sugar control. It is recommended to treat diabetics with a stable PD regimen and especially in case of diabetes patients may benefit from modern glucose-free PD solutions. Oral antidiabetics play a minor role due to renal elimination and the risk of hyoglycemia. Standard therapy for diabetics is subcutaneous insulin rather than intraperitoneal administration.

Optimum Electrolyte Composition of a Dialysis Solution

In patients undergoing peritoneal dialysis (PD) for end-stage renal failure, the optimum electrolyte composition of a dialysis solution is that which best serves the homeostatic needs of the body. Comparing the transperitoneal removal of electrolytes by conventional PD solutions (CPDSs) with that by normal kidneys, it is evident that peritoneal removal is in the lower range of what can be considered "normal." Given the electrolyte composition of CPDSs and a total dwell volume of 4 exchanges of 2 L each, approximately 90 mmol NaCl, 40 mmol K(+), 10 - 15 mmol HPO(4)(-) and 1 - 2 mmol Ca(2+) can be removed daily [plus 1 L ultrafiltration (UF)]. Na(+), Ca(2+), and Mg(2+) are supplied in CPDSs in concentrations close to their plasma concentrations, which makes their removal almost entirely dependent on UF. In UF failure (UFF), plasma levels of the foregoing ions will tend to rise, producing a higher diffusion gradient to compensate for their defective UF removal. Peritoneal removal of HCO(3)(-), HPO(4)(-), and K(+) are usually quite efficient because of the zero CPDS concentrations of these ions. Approximately 150 mmol HCO(3)(-) is lost daily with CPDSs, compensated for by the addition of 30 - 40 mmol/L lactate, or, with the use of multi-compartment bags, bicarbonate instead. However, a mixture of bicarbonate and lactate should be preferred as a buffer, to avoid intracellular acidosis from high levels of pCO(2) in the dialysis fluid. For patients on continuous ambulatory peritoneal dialysis (CAPD) without UFF and with some residual renal function, PD fluid concentrations of Na(+) 130 - 133 mmol/L, Ca(2+) 1.25 - 1.35 mmol/L, and Mg(2+) 0.25 - 0.3 mmol/L seem appropriate. With reduced UF after a few years of PD, the removal of fluid and electrolytes often becomes deficient. Dietary salt restriction can be prescribed, but it is hard to implement. The use of low-Na(+) solution (LNa) is a potential alternative. The reduction in osmolality resulting from Na(+) removal in LNa should preferably be compensated by the addition of glucose (G). In a recent study, a regimen including 1 LNa exchange daily (Na(+) 115 mmol/L) in a G-compensated solution showed very promising effects on blood pressure and fluid status. However, large-scale randomized controlled studies have to be performed to definitively settle the role of LNa in volume-overloaded patients.

Dialysis Survivors: Clinical Status of Patients on Treatment for More than 10 Years

Background: Although there are increasing numbers of long-term survivors on dialysis, there is remarkably little information about their medical and social wellbeing. Methods: A group of 46 current survivors of long-term dialysis at a single centre were identified and asked to complete a structured interview; selected routine blood tests were also reviewed. The group’s background and renal replacement history are described, along with frequencies of various complications. Results: Younger age and non-diabetic renal disease are associated with longer survival. Substantial morbidity accumulated over the time on dialysis, particularly vascular disease (57%) which was strongly linked to smoking history, as well as musculoskeletal complications (78%) and nutritional decline (80%). Encapsulating peritoneal sclerosis developed in 4 patients, after between 9 and 13 years of peritoneal dialysis. Conclusions: Despite accumulating morbidity, a surprisingly stable and socially well-adjusted group is revealed, with low rates of hospital admission in the majority. The pattern of complications may be influenced by modality choices.

Inflammation from sterile dialysis solutions and the longevity of the peritoneal barrier

There now exists a significant amount of evidence from both animal and human studies that commercially-available dialysis solutions result in the changes of the peritoneal barrier. Mesothelial cells undergo an epithelial-to-mesenchymal transition after less than one year of dialysis. After more than 6 years of peritoneal dialysis, there is extensive fibrosis and vasculopathy in the submesothelial compact zone. Clinical studies demonstrate that the structural changes apparently correlate with alterations in transport function and progressive ultrafiltration failure. The possible mechanisms of inflammation include macrophage peroxide production, acidic dialysis solutions, glucose and its degradation products, the presence of a foreign body, and the integrated signaling of the chemokine-cytokine cascade of the peritoneal cellular immune response in conjunction with biofilm on the peritoneal catheter. Basic and translational research efforts are discussed to portray our current knowledge in this area and to outline the remaining questions.

Peritoneal thickening is not inevitable in long-term peritoneal dialysis and is associated with peritoneal transport characteristics: a two-centre sonographic study

The peritoneum is subject to alterations in the life-long course of peritoneal dialysis (PD). Studies of the parietal peritoneum by non-invasive ultrasonography in PD patients are limited. We hypothesize that a prolonged PD duration is associated with a thicker peritoneum on ultrasonography and alterations in Doppler indexes of mesenteric vessels. We recruited two groups of patients, 18 who had >7 years of PD and 18 who had <12 months of PD. We excluded patients with active peritonitis, history of major abdominal surgery, cirrhosis or malignancy. We measured the sonographic thickness of the parietal peritoneum and Doppler indexes of mesenteric vessels by trans-abdominal ultrasonography at two PD units in Taiwan. We found no significant difference between two groups of PD patients in peritoneal thickness and in Doppler indexes. However, our univariate and multivariate analysis indicated that peritoneal thickness is associated with peritoneal transport characteristics (dialysate/plasma creatinine) but not with age, duration of dialysis, body height, body weight or Doppler index. The peritoneum is significantly thicker in rapid transporters than in slow transporters (RUQ: 0.59 +/- 0.40 mm versus 0.27 +/- 0.29 mm, P = 0.01; LUQ: 0.60 +/- 0.40 mm versus 0.27 +/- 0.32 mm, P = 0.016; LQ: 1.07 +/- 0.85 mm versus 0.48 +/- 0.53 mm, P = 0.026). In addition, rapid transporters have a marginally lower Doppler resistive index of the superior mesenteric artery (0.87 +/- 0.08 versus 0.90 +/- 0.10, P = 0.028). Our data showed that peritoneal thickening is not inevitable in long-term PD patients. Sonographic thickness in the parietal peritoneum is associated with transport characteristics. Rapid transporters have a significantly thicker peritoneum. The Doppler index of mesenteric vessels had no association with PD duration or transport characteristics. Trans-abdominal ultrasonography is non-invasive and useful in evaluating peritoneal characteristics of PD patients.

Salvage of Problematic Peritoneal Dialysis Catheters

Peritoneal dialysis (PD) is a markedly underutilized modality for permanent renal replacement therapy in the United States owing to a low rate of patient referral and high rate of patient dropout or transfer to hemodialysis. One cause for patient loss from PD is problematic PD catheters that often are removed rather than being subjected to simple surgical salvage procedures. We report three patients with problematic catheters and our approach to their management. The first patient developed erosion of the skin overlying the portion of the catheter between the deep and superficial cuffs after 6 months of PD. The second patient developed extrusion of the superficial cuff after 4 years of PD. The third patient demonstrated a localized abscess at the incision site for catheter insertion after 3 years of PD. Other than a mild superficial exit site infection and localized abscess in the second and third patient, respectively, there were no associated infections of the catheter tunnel and cuff or of the peritoneal cavity as determined by either clinical examination, ultrasound evidence of fluid collection, or cultures and white blood cell counts. All three cases were managed successfully by interventional nephrology on an outpatient basis and under local anesthesia without either catheter removal or placement of a new PD catheter. It was possible to continue uninterrupted PD in the first and third patients, while the second patient had temporary hemodialysis to allow for complete healing of the surgical wound. We conclude that in selected cases simple interventions can salvage problematic PD catheters and maintain patients on PD.

Evaluation of peritoneal transport properties at onset of peritoneal dialysis and longitudinal follow-up

The clinical determinants of baseline peritoneal membrane (PM) transport characteristics, as evaluated by a hypertonic peritoneal equilibration test (PET), remain ill-defined. Likewise, the longitudinal evolution of PM transport properties in peritoneal dialysis (PD) patients given automated PD (APD) and icodextrin still needs to be determined precisely. The aims of the present study were (1) to determine the clinical and biological factors affecting PM transport characteristics at PD onset and (2) to assess the longitudinal evolution of these markers. Seventy-two consecutive patients performed a baseline 3.86% glucose dialysate PET and were enrolled. Subgroups of 35 and 18 patients underwent another PET 1 and 2 year(s) later, respectively, and were included in the longitudinal part. For each patient, clinical and biological data were reviewed and PM transport markers calculated. At onset of PD, angiotensin-converting enzyme (ACE) inhibitor intake (r = 0.31, P = 0.01), presence of a diabetes (r = 0.26, P = 0.03) and body surface area (BSA) (r = 0.26, P = 0.03) independently affected the mass transfer area coefficient (MTAC) of creatinine. Serum albumin (r = -0.46, P<0.001) and net ultrafiltration (r = -0.33, P = 0.009) inversely correlated with MTAC creatinine. Sodium sieving was inversely correlated with BSA (r = -0.33, P = 0.01). Serum albumin also inversely correlated with albumin clearance (r = -0.39, P = 0.02). Finally, the independent covariates that affected alpha2-macroglobulin clearance were age (P = 0.03), diabetes (P = 0.01) and the level of residual renal function (P<0.01). Serum albumin decreased with time on PD (P = 0.02). A rise in small solute transport and a decrease in net ultrafiltration, but no change in protein clearances, were also observed after 2 years of PD. Transport properties across the PM, as evaluated by MTAC creatinine and sodium sieving determinations, are correlated with anthropometric characteristics (BSA) and by comorbid conditions (witnessed by the presence of diabetes, a low serum albumin concentration and the prescription of an ACE inhibitor). The short-term evolution (2 years) of the PM transport properties of patients on APD and icodextrin is still characterized by a progressive increase in small solute transport and a loss of ultrafiltration capacity, as documented in ancient studies, but not with a modification in protein clearances. This conclusion merits, however, to be further evaluated in a larger cohort of PD patients after a longer follow-up.

Sklerosierende Peritonitis als Komplikation bei Peritonealdialyse

Peritoneal dialysis (PD) is the preferred method of renal replacement therapy in childhood and adolescence while waiting for a kidney transplant. As major complication, encapsulating peritoneal sclerosis (EPS), sometimes also referred to as "sclerosing peritonitis", may develop after prolonged periods of PD and lead to severe therapeutical problems. A 20-year-old patient with a history of three unsuccessful kidney transplants due to recurrence of his focal segmental glomerulosclerosis presented after 9 years of PD with acute abdominal pain and reduced bowel movements. Infectious peritonitis was excluded, ultrafiltration with 800-1 000 ml per day with low (1,36 %) glucose dialysate was not impaired. Plain abdominal X-ray, ultrasound and CT-scan illustrated characteristic peritoneal calcifications. Diagnosis of EPS was confirmed by peritoneal biopsy. The patients was switched to hemodialysis, enteral nutrition was continued, and the follow-up (now 16 months) was uncomplicated with the exception of a sterile ascites, which was twice relieved. Diagnostic and therapeutic options are discussed. In contrast to most reports, EPS may develop with unchanged ultrafiltration after prolonged periods of PD. We recommend regular functional and imaging studies in patients at risk.

Histologic Change of Peritoneal Membrane in Relation to Adequacy of Dialysis in Continuous Ambulatory Peritoneal Dialysis Patients

Long-term exposure of peritoneal membrane to bioincompatible dialysis solutions leads to structural changes and loss of ultrafiltration capability. We studied the possible relationship between histologic change and the transport characteristics of peritoneal membrane and adequacy of dialysis in continuous ambulatory peritoneal dialysis (CAPD) patients. The study included 18 CAPD patients (11 men, 7 women) who underwent a peritoneal biopsy either at initiation of treatment (group A, n = 9) or after a mean of 4 years on CAPD (group B, n = 9). The morphologic changes in the mesothelial cells and the vascular compartment and the thickness of the submesothelial collagenous zone were estimated and compared with observations from 6 patients with normal renal function who underwent biopsy of the parietal peritoneum during abdominal surgery. The relationship of the observed changes in CAPD patients to results from a peritoneal equilibration test (PET) and to adequacy of dialysis [total weekly creatinine clearance (CCr) and Kt/V urea] were also investigated. The main histologic changes in both groups of patients were loss of mesothelial cells and decrease in the normal mesothelial surface, thickening of the submesothelial collagenous zone, and presence of vascular hyalinosis. The thickness of the submesothelial collagenous zone in both groups of patients was significantly greater than that found in controls (410 mum and 580 mum vs 50 mum, p < 0.05). Although no significant difference was found between morphologic change in the peritoneal membrane of uremic patients starting on CAPD and those who had been on peritoneal dialysis (PD) for a mean period of 4 years, a trend was observed toward more severe lesions in the latter patients. The PET, CCr, and Kt/V urea were not significantly different in the two groups of patients. Those parameters also showed no significant changes when examined at initiation of CAPD and after a mean of 4 years of PD in the same patients (group B). No significant correlations were observed between the histologic changes and the PET, CCr, or Kt/V in both groups of patients. Significant structural changes are observed in the peritoneal membrane of uremic patients, and those changes become worse with CAPD treatment. Structural changes are not followed by functional changes during the first 4 years on CAPD.

Origin of Urothelial Carcinoma After Renal Transplant Determined by Fluorescence In Situ Hybridization

Development of malignancy after organ transplantation is uncommon, but is complicated by chronic immunosuppression. We report the use of fluorescence in situ hybridization to determine the origin of transitional cell carcinoma after cadaveric renal transplantation, and discuss issues regarding surgical management in such cases. CASE REPORT A 45-year-old woman with end stage renal disease secondary to interstitial nephritis underwent cadaveric renal transplantation after 4 years of peritoneal dialysis. The donor was a 29-year-old man with no significant medical history. Neither donor nor recipient had risk factors for transitional cell carcinoma. The immunosuppression regimen included cyclosporine, prednisone and tacrolimus. Serum creatinine nadired at 1.1 mg./dl. (normal 0.7 to 1.2). Four years after transplantation the patient presented with gross hematuria, elevated creatinine (4.1 mg./dl.) and graft hydronephrosis necessitating percutaneous drainage. Upper tract imaging demonstrated atrophic native kidneys without mass lesions. Computerized tomography and cystoscopy revealed a sessile bladder mass enveloping the transplant ureteral orifice (fig. 1). Biopsies confirmed high grade transitional cell carcinoma invading the muscularis propria. There was uncertainty regarding the origin of this tumor, with native bladder mucosa and urothelium from the transplant collecting system or ureter as possibilities. Fluorescence in situ hybridization showed the presence of only X chromosomes within resected tumor cells (fig. 2). Exploratory laparotomy demonstrated extensive lymphadenopathy, and cystectomy was aborted. DISCUSSION

Peritoneal dialysis in end-stage renal disease patients with preexisting chronic liver disease and ascites

purpose: Hemodialysis in patients with chronic liver disease and ascites may be complicated by intradialytic hypotension, limiting the amount of ultrafiltration and resulting in massive ascites. Successful maintenance peritoneal dialysis (PD) has not been previously reported as an alternative to hemodialysis in this population. patients and methods: Nine patients with chronic renal failure, chronic liver disease, and tense ascites prior to beginning PD are described. All chronic PD catheters were placed percutaneously by the nephrology staff. Seven patients were maintained primarily on continuous ambulatory peritoneal dialysis, whereas two were on intermittent peritoneal dialysis. results: PD catheters were placed without serious hemorrhage or bowel injury. PD provided adequate clearance and volume maintenance for each patient. Fifteen episodes of peritonitis occurred in 18 patient-years of PD. All episodes of peritonitis were successfully treated with intraperitoneal antibiotics without catheter removal. Only one patient had a decline in the serum albumin level of 0.5 g/dL or more during the course of chronic PD. Three of the nine patients are still alive and on PD for durations of 18 to 24 months. One patient insidiously developed sclerosing peritonitis after 8 years on PD and is now on hemodialysis, and another patient switched to hemodialysis because she was no longer able to care for herself or to manage her PD. Four patients died while maintained on PD; three deaths were due to complications of liver failure within the first 4 months of PD and the fourth was due to empyema after 4 years of PD. conclusion: PD can be used successfully to treat chronic renal failure in patients with chronic liver disease and ascites when the liver disease itself is not rapidly fatal. PD may be better tolerated than hemodialysis and perhaps should be the renal replacement treatment of choice in these patients.

Sclerosing Encapsulating Peritonitis: Report of a Case With Small Bowel Obstruction Managed by Long-Term Home Parenteral Hyperalimentation, and a Review of the Literature

Sclerosing peritonitis has recently emerged as a complication of peritoneal dialysis associated with a high morbidity and mortality. These patients experience the characteristic syndrome of nausea, vomiting, abdominal pain, partial small bowel obstruction, and impaired ultrafiltration. A pathologic finding is the replacement of mesothelial cells with a thick layer of nondistensible fibroconnective tissue. We report here a 58-year-old white woman who developed peritoneal sclerosis after 4 years of peritoneal dialysis, including 3 years of continuous ambulatory peritoneal dialysis. Risk factors included peritoneal exposure to low concentrations of formaldehyde and a 1-week exposure to long-dwell acetate dialysate. Laparotomy for partial small bowel obstruction with resection of the involved segment was complicated by enterocutaneous fistulae, which improved only on cessation of oral intake and treatment with home parenteral nutrition. We have reviewed the literature to find 20 cases of sclerosing peritonitis in patients on peritoneal dialysis. A 78% mortality rate is reported in cases that had surgical intervention. We conclude that the use of long-term parenteral nutrition with cessation of oral intake may be necessary in the management of sclerosing encapsulating peritonitis.

Diabetic Nephropathy Is a Hyperglycemic Glomerulopathy

When last commented on in theArchivestwo years ago, 1 the diabetic renal-retinal syndrome was viewed as a usually serious and often devastating complication of long-standing diabetes for which near-term improvement in prognosis was likely. At that time, it was noted that about half of insulindependent diabetics experience renal failure in a mean of 20 years. Survival of treated uremic diabetics was dismal, with only one in five patients surviving beyond two years of peritoneal dialysis and about one in two living longer than three years after a cadaveric kidney transplant or when sustained by hemodialysis. Interest in diabetic nephropathy since then has been intensified by numerous articles indicating that glomerulosclerosis, the major renal pathological finding in protracted diabetes, is a consequence of hyperglycemia per se. Evidence supporting this contention is drawn from two sources—animal models of diabetes and the fate of renal allografts from nondiabetic donors to diabetic