Encapsulating peritoneal sclerosis

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 from 0.7% to 7.3%, and the rate appears to be higher in patients receiving long-term treatment. Most data from Japan has shown an overall incidence of 2.5% with an evident negative effect of increasing duration of PD, which also augments mortality. Since EPS occurred after withdrawal from PD in more than half of the patients, strict monitoring is necessary when a long-term PD patient is withdrawn from PD. Maintaining patients on standard PD for more than 8 years using conventional solutions is associated with a substantial risk for development of EPS. Appropriate treatment according to the disease stage is most important in EPS treatment. Therefore, when examining a PD patient complaining of gastrointestinal symptoms, the possibility of EPS has to be kept in mind. Basic therapeutic tactics for EPS include appropriate use of steroids. If the state of bowel obstruction persists, laparotomy and enterolysis should be performed to obtain a complete cure. It is now recognized that EPS is not a fatal complication of PD.     

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.     

Activation of matrix metalloproteinase-2 causes peritoneal injury during peritoneal dialysis in rats.

BACKGROUND: Sclerosing peritonitis (SP) and encapsulating peritoneal sclerosis (EPS) are serious complications of continuous ambulatory peritoneal dialysis. Although we have shown previously that matrix metalloproteinase-2 (MMP-2) is increased in peritoneal injury leading to SP/EPS, most of the MMP-2 in the dialysate drained from the peritoneal cavity was the latent form that was lacking activity. In the present study, we investigated whether MMP-2 causes peritoneal injury. METHODS: To create an animal model of peritoneal injury, we administered intraperitoneally chlorhexidine gluconate to rats. Dialysate drained from these rats was analysed by gelatin zymography and MMP-2 activity was analysed by an in situ film zymography method. In vitro myofibroblasts were cultured in collagen three-dimensional culture and then MMP-2 in conditioned medium from the culture was analysed by gelatin zymography. RESULTS: Zymographic analysis revealed that latent form MMP-2 levels were high in the dialysate from peritoneal injury rats, whereas the active form was barely detectable. MMP-2 activity in the peritoneal tissue of the peritoneal injury rats was strongly detected by in situ film zymography. In vitro myofibroblasts were promoted to produce MMP-2 and to activate MMP-2 in collagen three-dimensional culture. CONCLUSIONS: In the present model, most of the MMP-2 was in the latent form, but activation of MMP-2 was promoted in the peritoneum during peritoneal injury. Activated MMP-2 may be associated with the progression of peritoneal injury.     

Multidisciplinary clinical strategies for encapsulating peritoneal sclerosis in peritoneal dialysis: Update from Japan

Peritoneal dialysis is established as a first‐line standard renal replacement therapy for end‐stage renal disease. However, the development of encapsulating peritoneal sclerosis has been a critical complication among long‐term peritoneal dialysis patients. During the past decade, multidisciplinary approaches have been used to suppress encapsulating peritoneal sclerosis. The present article reviews the historical and present status of encapsulating peritoneal sclerosis in Japan.     

Peritoneal nitric oxide is a marker of peritonitis in patients on continuous ambulatory peritoneal dialysis

Nitric oxide plays an important role in mediating the inflammatoryprocess. The aim of this study was to evaluate if nitric oxideproduction was increased during peritonitis in patients receivingcontinuous ambulatory peritoneal dialysis (CAPD), and the associationwith the prognosis. The study population comprised 21 patientswith 22 episodes of peritonitis. Fifteen patients without peritonitiswere controls. Nitrate was measured by HPLC and nitrite by theGriess method, to reflect nitric oxide production. Peritonealdialysate effluent and plasma were collected from six patientsduring peritonitis and 1 week after treatment to study changesin dialysate:plasma ratio. In 15 patients, nitrite was measuredduring peritonitis and every 3 days for 2 weeks or until normalizedfor evolutional changes. The dialysate plasma ratios of nitrateand nitrite during peritonitis were reduced 26% and 41.5%, respectively,after 1 week of treatment, indicating the peritoneal productionof nitric oxide during peritonitis. In the evolutional study,a 5.1-fold increase of peak nitrite levels in bacterial peritonitis(n=13) and a 2.5-fold increase in fungal peritonitis (n=3) wereobserved compared to controls. Nitrite gradually declined tocontrol levels (9.3±7.2 days) after effective antibiotictreatment, but took longer than to normalize leukocyte countin the peritoneal dialysate effluent (3.9±1.9 days).In four patients with refractory peritonitis (Candida infectionin three, Acinetobacter infection in one), the nitrite levelsremained elevated 2-fold despite treatment, and the catheterswere removed. It is concluded that nitrite levels in peritonealdialysate effluent may serve as a marker to assess treatmentefficacy in CAPD patients with peritonitis.     

Increase of matrix metalloproteinase-2 in dialysate of rat sclerosing encapsulating peritonitis model

SUMMARY: Sclerosing peritonitis (SP) and sclerosing encapsulating peritonitis (SEP) are serious complications of continuous ambulatory peritoneal dialysis (CAPD). the mortality rate of SP/SEP is extremely high. It is important to clarify the mechanism of progression of SP/SEP, and to prevent this complication. We prepared an animal model of SEP by intraperitoneal administration of chlorhexidine gluconate (CHX) using male Sprague-Dawley rats. Dialysate drained from these animals was analysed by gelatin zymography. In this animal model of SEP, fibrous peritoneal thickening accompanied by cellular infiltration and peritoneal adhesion, were observed. Four of six rats presented with a so-called abdominal cocoon. an increase of peritoneal absorption of glucose was also confirmed. Zymographic analysis revealed that the matrix metalloproteinase-2 (MMP-2) level was high in the dialysate from the animal model, although MMP-9 was hardly detected. From these results, the MMP-2 level in drained dialysate was considered to increase in SP/SEP. Matrix metalloproteinase-2 might be associated with the progression of SP/SEP.     

Relapsing Bacillus licheniformis peritonitis in a continuous ambulatory peritoneal dialysis patient

Bacillus licheniformis is a rare pathogen in continuous ambulatory peritoneal dialysis (CAPD) peritonitis. Only one case of B. licheniformis peritonitis has been previously reported but relapsing peritonitis by same species has not been reported. A 31-year-old man undergoing CAPD was admitted to our hospital with diarrhoea and turbid peritoneal effluent. Although B. licheniformis was cultured at his previous admission, we did not consider the species as a pathogen. After the same species was cultured twice consecutively at the subsequent admission, we confirmed that B. licheniformis was a pathogen of CAPD peritonitis. After appropriate intraperitoneal antibiotics therapy, the patient improved. He is currently undergoing CAPD without catheter removal.     

Cellular response to peritonitis among peritoneal dialysis patients

White blood cell counts and differential cell counts were performed on 249 peritoneal dialysis effluents from 48 patients using chronic peritoneal dialysis. The finding of more than 50% polymorphonuclear leukocytes in the dialysate was a more sensitive indicator of peritonitis than was an absolute cell count of 100 cells/microL. This finding was true for patients using intermittent peritoneal dialysis, continuous ambulatory peritoneal dialysis, and continuous cycling peritoneal dialysis.     

Longitudinal changes in peritoneal kinetics: the effects of peritoneal dialysis and peritonitis

BACKGROUND.: Peritoneal infection and poor ultrafiltration continue to bethe major causes of treatment failure in CAPD. The combinedeffects of peritonitis and the continuous exposure to dialysisfluid remain the most likely candidates affecting the peritoneumin the long term. The purpose of this study was to observe theeffects of peritonitis and dialysis on longitudinal peritonealfunction. METHODS.: The peritoneal equilibration test (PET) was utilized to quantifylongitudinal changes in low-molecular-weight solute transfer(D/P_creat) and ultrafiltration (UF) in 233 patients treatedwith CAPD. Of these, 166 represented an unselected cohort (Group1) studied prospectively from commencing treatment for up to54 months, and 67 were selected patients (Group 2) with PETdata available at commencement of the study, having been ondialysis for a minimum of 18 months. PETs were performed either6-monthly or following peritonitis episodes. RESULTS.: Data on the short-term effect of peritonitis kinetics were pooledfor groups 1 and 2. Single, isolated episodes (n = 86) had nosignificant effect on D/P_creat or UF, whereas recurrences orclusters of infection (n = 70) caused increases in D/Pcreatand reductions in UF, the significance of which increased withthe number of episodes. There were significant correlationsbetween both changes in D/P_creat and UF with the cumulativedialysate leukocyte count, regardless of infecting organism,suggesting that intensity of peritoneal inflammation is alsoimportant. Those organisms associated with greater change inperitoneal kinetics, e.g. S. aureus, Pseudomonas, also had thehighest neutrophil counts. The longitudinal changes in peritoneal kinetics were analysedfor patients in group 1 only. There was a highly significantincrease in D/P_creat after 6 months treatment; this increasedfurther with time on treatment, reaching further significanceat 42 and 48 months. There was an associated reduction in UF.In view of the short-term effects of peritonitis on kineticsgroup 1 was further subdivided into patients who were eitherperitonitis free or only experienced isolated infections, group1a, and those that had multiple infection episodes, group 1b.Treatment drop-out, due to death or technical failure occurredat double the rate in group 1b, who also had significantly higherD/P_creat and lower UF at 1, 6, 12, 18 and 24 months of treatment.Group 1a subsequently caught up, however, indicating that peritonitisis not the only factor influencing long-term changes in peritonealkinetics. CONCLUSIONS.: These data suggest that solute transfer increases and UF declineswith time on peritoneal dialysis. This process is exacerbatedand accelerated by peritonitis, and appears to be proportionalto the degree of associated inflammation and number of infectionsin close proximity.     

Idiopathic eosinophilic peritonitis in continuous ambulatory peritoneal dialysis: experience with percutaneous catheter placement

BACKGROUND: Peritoneal fluid eosinophilia (PFE), which is classically associated with idiopathic eosinophilic peritonitis (EP), has been known as a common event in patients on continuous ambulatory peritoneal dialysis (CAPD). However, our recent retrospective study of CAPD patients following percutaneous catheter placement showed that PFE occurred rarely. The aim of this prospective study was to clarify the incidence and characteristics of idiopathic EP and PFE in patients on CAPD following percutaneous catheter placement. METHODS: Forty-eight patients on CAPD following percutanous catheter placement were recruited for the present study. Peritoneal dialysis was initiated immediately after catheter insertion without break-in period. A cytological study of dialysate was performed on days 1, 2, 3, 4, 5, 6, 7, 14 and 30 after initiation of CAPD, and then monthly for 6 months. In addition, a cytological study was performed also when a patient revealed abdominal pain or cloudy peritoneal effluent. RESULTS: PFE developed in three (6.3%) patients during the study period. The incidence of idiopathic EP and PFE without any clinical findings suggestive of PD-related peritonitis was 2.1% and 4.2% respectively. All cases of PFE, including idiopathic EP, developed on a mean of 13 day following initiation of CAPD and resolved spontaneously after a mean of 7 days. There was no significant difference in IgE levels or the occurrence of peripheral blood eosinophilia between patients with PFE and those without. CONCLUSION: Idiopathic EP is infrequent among patients on CAPD following percutaneous catheter placement, but should be differentiated from infectious PD-related peritonitis.     

Late presentation of encapsulating peritoneal sclerosis following renal transplantation and the potential under‐reporting of the incidence and prevalence of encapsulating peritoneal sclerosis

Encapsulating peritoneal sclerosis is an infrequent but potentially devastating complication of peritoneal dialysis. The reported incidence and prevalence of encapsulating peritoneal sclerosis vary markedly between countries. Currently, peritoneal dialysis vintage remains the major risk factor for encapsulating peritoneal sclerosis, and dialysis vintage differs between countries due to the relative competing risks of transplantation, availability of haemodialysis and peritonitis. However, the diagnosis of encapsulating peritoneal sclerosis is often only established when patients have transferred modality to transplantation or haemodialysis. Switching treatment modality may potentially lead to an under‐reporting of encapsulating peritoneal sclerosis, as many countries which collect data on dialysis patients in national registries often have separate registries for dialysis and transplant patients, and this may potentially lead to under‐reporting of encapsulating peritoneal sclerosis in patients presenting after renal transplantation. Secondly, the question arises as to how long former peritoneal dialysis patients should be followed before a diagnosis of encapsulating peritoneal sclerosis can be confidently excluded. To highlight this point, we present four cases that developed symptomatic encapsulating peritoneal sclerosis more than 5 years, and in once case more than 10 years after the discontinuation of peritoneal dialysis. Delayed or late presentation may not only delay the diagnosis, but also risk surgical interventions by non‐specialists. A more robust system is required to record cases of encapsulating peritoneal sclerosis to determine the incidence and prevalence, and so provide accurate information to both patients and clinicians as to the risks of long‐term peritoneal dialysis therapy.     

Epidemiology of culture isolates from peritoneal dialysis peritonitis patients in southern India using an automated blood culture system to culture peritoneal dialysate

Aim: Continuous ambulatory peritoneal dialysis (CAPD) is a major form of therapy for chronic end stage renal disease patients, which may lead to CAPD‐associated peritonitis. The spectrum of organisms associated with CAPD peritonitis varies geographically. Not much data is available regarding this from southern India. The aim of this study was to characterize the spectrum of organisms associated with CAPD peritonitis in this region and observe the utility of automated blood culture systems to culture peritoneal dialysate. Methods: Ninety episodes of peritonitis were cultured over a span of 3 years using an automated blood culture system. Results: The yield of culture positivity was 50%. The most predominant organism was found to be coagulase‐negative Staphylococcus spp. (21.1%) followed by Enterobacteriaceae (12.2%). Other organisms isolated were non‐fermenting Gram‐negative bacilli (4.4%), Pseudomonas aeruginosa (3.3%), α‐haemolytic Streptococci (3.3%), Candida spp. (2.2%), Staphylococcus aureus (1.1%), β‐haemolytic Streptococci (1.1%) and Micrococci (1.1%). A high degree of resistance to third generation cephalosporins (66.7%) was noted amongst the Gram‐negative bacilli. Also, all the Gram‐negative bacilli isolated from patients who had prior empirical antibiotic therapy of ceftazidime before arrival at the centre, were resistant to third generation cephalosporins. Conclusion: A varied spectrum of organisms isolated from peritoneal dialysate compared to the global scenario was observed. Also, a high degree of third generation cephalosporin resistance was noted amongst the Gram‐negative bacilli. Thus, it is suggested that the empirical therapy should be dependent on the local epidemiology.     

Nocardia peritonitis and abdominal abscess complicating continuous ambulatory peritoneal dialysis

Peritonitis is a common problem in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) and represents the most frequent cause of peritoneal catheter loss and discontinuation of CAPD. The incidence of peritonitis remains less than one episode per patient year of treatment. Common bacteria, particularly staphyloccal species, are the usual causative agents. Fungi and higher bacteria such as Nocardia as aetiological agents have been infrequent in patients undergoing CAPD. We report a case of Nocardia nova peritonitis complicated by an intra‐abdominal abscess requiring surgical drainage and a protracted course of antibiotics.     

Ultrasonography in the management of exit site infections in peritoneal dialysis patients

AIM: To assess the efficacy of using ultrasonography (USG) in monitoring the progress of exit site infection (ESI) in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). METHODS: Twenty-two cases of newly diagnosed ESI and 20 cases with normal exit sites as controls were assessed by using USG. The exit sites were reassessed by using USG after finishing a course of antibiotic therapy, and the sonographic findings were correlated with the clinical outcome. RESULTS: Out of the 22 cases of ESI, 21 cases had definite sonolucent zones around the external cuffs, while one case had normal sonographic findings. Of the 20 control cases of normal exit sites, 16 had normal sonographic findings, and four had sonolucent zones around the external cuffs. Exit site infections correlated with positive sonographic findings as compared to normal exits (P <0.0001). The 21 cases of ultrasonic-positive ESI were re-examined after antibiotic therapy, and 10 of these had a post-treatment sonolucent rim around the distal cuff < or =1 mm thick, while 11 cases were persistently > mm thick. The former group was shown to have a more favourable outcome (P=0.013). And despite variable USG findings, all eight patients with Pseudomonas aeruginosa-related ESI had an unfavourable clinical outcome. CONCLUSION: Ultrasonography of the exit sites in CAPD patients is a useful adjunctive tool in the management of ESI. A sonolucent zone around the external cuff >1 mm thick following a course of antibiotic treatment and the involvement of the proximal cuff are associated with poor clinical outcome. In ESI caused by Pseudomonas aeruginosa, the clinical outcome was uniformly poor irrespective of the sonographic findings.