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

Abstract

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.

Inflammatory macrophages switch to CCL17‐expressing phenotype and promote peritoneal fibrosis

“…In addition to changes in the permeability of the peritoneal membrane, the dialysis process itself frequently triggers peritoneal fibrosis (PF), which progressively reduces membrane function, resulting in dialysis failure [2][3][4][5]. In a small percentage of patients, severe PF occurs primarily in the visceral peritoneum, resulting in encapsulating peritoneal sclerosis (EPS), which is a catastrophic complication with obscure pathogenesis and a high mortality rate [5][6][7][8][9]. Such membrane failure is characterized by thickening of the peritoneum, with accumulation of inflammatory cells and α-smooth muscle actin (αSMA) + myofibroblasts 56 Y-T Chen et al [10][11][12].…”

Clinical risk factors and outcomes of massive ascites accumulation after discontinuation of peritoneal dialysis

“…Clinically, 38% of EPS cases developed after an episode of bacterial peritonitis [23], and 63% occurred after PD withdrawal for various reasons [6]. Although bacterial peritonitis [4,23] and PD withdrawal [4,24] both appear to be associated with the development of EPS, patients without peritonitis still maintain predisposing factors for the development of EPS. Despite the huge discrepancy between the control and study groups, our study still provides clinical clues.…”

A Matrix Metalloproteinase-2-Based Nomogram to Assess the Risk of Encapsulating Peritoneal Sclerosis in Peritoneal Dialysis Patients

“…We calculated the sample size using the formula provided by Riley et al [ 9 ]. The number of cases is 27 with a 95% confidence interval and 1.8% prevalence rate [ 10 ]. Possible factors associated with EPS were analyzed using univariable logistic regression followed by multivariable logistic regression.…”