| Abstract|| |
Encapsulating peritoneal sclerosis (EPS) is the most serious complication of long-term peritoneal dialysis (PD). EPS is diagnosed by clinical symptoms (abdominal pain, nausea, vomiting, diarrhea, and anorexia.) and image study (intestinal expansion, peritoneal thickening and calcification, and ascites.). Steroid therapy and surgery are recommended as the treatment of EPS. Here, we report a case of EPS with steroid-resistant massive ascites successfully treated with peritoneal lavage. A 59-year-old female with end-stage kidney disease secondary to hypertension was started on PD in 2003. Due to recurrent exit-site infection and two episodes of peritonitis, she was transferred to hemodialysis (HD), and her PD catheter was removed in 2011. In February 2012, six months after discontinuation of PD, she was found to have massive ascites on abdominal computerized tomography (CT). The patient was diagnosed to have EPS and was started on prednisolone. Despite eight months of prednisolone therapy, the ascites did not decrease. Therefore, the PD catheter was inserted again, and she was started on daily peritoneal lavage from September 2012. After four months of daily peritoneal lavage, her ascites disappeared in January 2013. The PD catheter was removed in July 2013. Steroid treatment was completed in May 2014, and there has been no recurrence of ascites since then. The evaluation of ascites by abdominal CT is important in a patient on long-term PD. Since EPS may appear any time after the discontinuation of PD, it is important to start screening abdominal CT shortly after the discontinuation of PD. Steroid-resistant massive ascites can be successfully treated with peritoneal lavage.
|How to cite this article:|
Kaneshiro N, Imai N, Sakurada T, Shibagaki Y. Encapsulating peritoneal sclerosis with steroid-resistant massive ascites successfully treated by peritoneal lavage. Saudi J Kidney Dis Transpl 2018;29:985-8
|How to cite this URL:|
Kaneshiro N, Imai N, Sakurada T, Shibagaki Y. Encapsulating peritoneal sclerosis with steroid-resistant massive ascites successfully treated by peritoneal lavage. Saudi J Kidney Dis Transpl [serial online] 2018 [cited 2020 Jan 17];29:985-8. Available from: http://www.sjkdt.org/text.asp?2018/29/4/985/239647
| Introduction|| |
Encapsulating peritoneal sclerosis (EPS) is the most serious complication of long-term peritoneal dialysis (PD). EPS is defined as a syndrome causing sustained, intermittent, or recurrent ileus-like symptoms due to wide range of adhesion of the diffusely thickened peritoneum. EPS is diagnosed by clinical symptoms (abdominal pain, nausea, vomiting, diarrhea, and anorexia.) and imaging findings (intestinal expansion, peritoneal thickening and calcification, and ascites). EPS is divided into four stages, and it usually occurs during PD or within two years after the withdrawal of PD.,, It is difficult to diagnose EPS early during its course and usually abdominal computerized tomography (CT) is performed for screening. Steroids and surgical therapy are currently the standard treatment of EPS depending on their stage. We report a case of EPS with steroid-resistant massive ascites successfully treated by peritoneal lavage.
| Case Report|| |
Informed consent was obtained from the patient before reporting this case. A 59-year-old female with end-stage renal disease due to hypertension was started on PD in September 2003 for uremic symptoms. Automated PD with a daytime dwell with icodextrin was used as her PD regimen. Her course was uncomplicated until September 2007, when her urine volume started to reduce significantly and she started to show symptoms of fluid overload. She was started on once weekly hemodialysis (HD) as a combination therapy with her PD. In July 2011, for recurrent exit-site infection and two episodes of peritonitis, one of which was caused by Staphylococcus capitis, it was decided to stop her PD. The PD catheter was removed, and she was started on thrice weekly HD. No signs of EPS were observed, and no pathological abnormality was seen on peritoneal biopsy at the time of PD catheter removal.
She was a high-risk candidate for EPS considering her long-term PD and history of peritonitis and was decided to be followed up regularly with screening abdominal CT. There were no ascites in September 2011; however, in February 2012, she was noticed to have massive ascites without intestinal expansion and peritoneal thickening [Figure 1]a and [Figure 1]b. Her nutritional status was good at that time. After extensive workup for the newly developed ascites, she was diagnosed to have early EPS and was started on 10 mg/day of oral predni-solone. The dose of prednisolone was increased to 20 mg/day in May 2012 [Figure 2]. Despite eight months of prednisolone therapy, she continued to have massive ascites [Figure 1]c; and in September 2012, a decision was made to reinsert the PD catheter and to initiate daily peritoneal lavage. Her ascites gradually decreased and finally disappeared in January 2013 after four months of daily peritoneal lavage. The PD catheter was removed in July 2013, and no recurrence of ascites has been noticed since then [Figure 1]d.
|Figure 1: Serial abdominal computed tomography scans showing the disappearance of ascites in the study patient.|
Large amount of ascites appeared in February 2012. PD catheter was reinserted, and daily peritoneal lavage was started in September 2012. Ascites disappeared in January 2013 and has not recurred so far.
Click here to view
|Figure 2: Clinical course of the study patient.|
Her peritoneal dialysis catheter was removed, and she was started on thrice weekly HD in July 2011. She was diagnosed with early EPS and was started on oral prednisolone in February 2012.PD catheter was reinserted, and daily peritoneal lavage was started in September 2012. Ascites disappeared in January 2013. PD catheter was removed again in July 2013.
HD: Hemodialysis, PD: Peritoneal dialysis.
Click here to view
| Discussion|| |
In this case report, we have shown that peritoneal lavage can be effective for steroid-resistant massive ascites in EPS. We also confirmed that it is important to start screening abdominal CT early after the discontinuation of PD.
The patient being reported was considered to be at high risk for EPS since she had eight years of long-term PD period and a history of peritonitis. Although the effectiveness of renin-angiotensin-aldosterone system (RAAS) inhibitors against peritoneal fibrosis is poor, the patient was already on this therapy. Currently, at our institution, patients with PD duration of <5 years and peritoneal equilibrium test (PET) category of “less than high” are screened for EPS for at least one year after discontinuation of PD. Patients with PD duration of more than five years, frequent peritonitis, or PET category of “high” are screened for EPS for at least two years after discontinuation of PD. If signs of EPS develop, oral prednisolone is started. As per our institution protocol, she was regularly followed up with abdominal CT, which leads to the detection of massive ascites early after the discontinuation of PD.
In our case, EPS was diagnosed eight months after discontinuation of PD. In Japan, it is reported that 41.8% of the EPS are diagnosed while continuing PD, and the others are diagnosed, usually within two years, after discontinuation of PD. Only four cases of EPS that developed more than five years after discontinuation of PD have been reported.
Staging of EPS is done as follows: pre-EPS stage, inflammatory stage, encapsulating stage, and ileus stage. In our case, although there was massive ascites, intestinal expansion, cocooning, and peritoneal thickening were not confirmed on abdominal CT. She was diagnosed to have early EPS either pre-EPS stage or inflammatory stage.
Regular follow-up with screening abdominal CT is essential to diagnosis and initiate the treatment of EPS early. Steroid therapy is currently the standard treatment for early-stage EPS. Other immunosuppressive drugs, such as tamoxifen or total parenteral nutrition, are used if steroid therapy fails. If these therapies are ineffective and if ileus symptoms continue, the surgical treatment has been advocated. Although it needs further evaluation, our case showed that peritoneal lavage can be effective for steroid-resistant massive ascites.
| Conclusion|| |
It is important to start screening abdominal CT for ascites early after the discontinuation of PD. Peritoneal lavage can be effective for steroid-resistant massive ascites.
Conflict of interest: None declared.
| References|| |
Nomoto Y, Kawaguchi Y, Sakai S, et al. Scleosing encapsulating peritonitis (SEP) in patients on continous ambulatory peritoneal dialysis. Definition, diagnosis and treatment recommendations, 1997 update. J Jpn Soc Dial Ther 1998;31:303-11.
Nakamoto H. Encapsulating peritoneal sclerosis – A clinician's approach to diagnosis and medical treatment. Perit Dial Int 2005;25 Suppl 4:S30-8.
Nakamoto H, Kawaguchi Y, Suzuki H. Encapsulating peritoneal sclerosis in patients undergoing continuous ambulatory peritoneal dialysis in Japan. Adv Perit Dial 2002;18:119-23.
Nakayama M, Ikeda M, Katoh N, et al. Is encapsulating peritoneal sclerosis a threatening issue in continuous ambulatory peritoneal dialysis? The Japanese experience. Perit Dial Int 2003;23 Suppl 2:S132-3.
Brown EA, Van Biesen W, Finkelstein FO, et al. Length of time on peritoneal dialysis and encapsulating peritoneal sclerosis: Position paper for ISPD. Perit Dial Int 2009;29:595-600.
Hiramatsu N, Yoshida H, Neishi J, et al. Encapsulating peritoneal sclerosis developed 11 years after the discontinuation of peritoneal dialysis: A case report. J Jpn Soc Dial Ther 2003;36:1631-5.
Dr. Nagayuki Kaneshiro
Division of Nephrology and Hypertension, Kawasaki Municipal Tama Hospital, Kawasaki, Japan 1-30-37 Shukugawara, Tama-ku, Kawasaki, Kanagawa
[Figure 1], [Figure 2]