Peritoneal Sclerosis in Chronic Peritoneal Dialysis Patients: Analysis of Clinical Presentation, Risk Factors, and Peritoneal Transport Kinetics

Abstract

Objective To analyze clinical features of peritoneal sclerosis (PS) in a group of peritoneal dialysis (PD) patients, and to compare potential risk factors and peritoneal transport characteristics with a control group matched for duration of PD. Design Study 1: Retrospective study of 16 PD patients with PS. Study 2: Case-control study comparing 10 patients with evident PS to 30 control patients who were matched for duration of PD. Setting Continuous Ambulatory Peritoneal Dialysis unit in the Academic Medical Centre in Amsterdam. Results The incidence of PS was 3.5 per 1000 patient years. PS was diagnosed either during PD (n = 10), in patients on hemodialysis (n = 2), or after successful transplantation (n = 4). Presenting symptoms were bowel obstruction, ascites, blood-stained effluent, and impaired net ultrafiltration. Macroscopic confirmation of the diagnosis was possible in 13 patients. Sclerotic encapsulation was present in 8 of them. Patients with PS were divided into three groups based on clinical symptoms and typical macroscopical findings. In category I the diagnosis PS was obvious (10 patients), in category II the diagnosis was highly suggestive (3 patients), and in category III it was doubtful (3 patients). Treatment was conservative in most patients. Surgical treatment was only possible in four and immunosuppressive therapy was given in 5 patients. Peritoneal sclerosis was the direct cause of death in 1 patient. Five patients died during follow-up due to other causes. At present, 7 patients are well and 3 patients (all from category I) still have recurrent bowel obstruction. Compared to matched controls, no difference existed in peritonitis incidence, or in the percentage of patients with former renal transplantations. The number of patients treated with β-blocking agents and the number of previous abdominal surgeries were not different. The number of catheter-related surgical procedures was higher in the PS patients than in the control group. The mass transfer area coefficient (MTAC) of creatinine was higher in PS patients and net ultrafiltration with 1.36% glucose was lower. The estimated cumulative glucose exposure until the diagnosis of PS was made was larger in PS patients than in their controls. This difference was already present in the first year of PD treatment in 8 of 10 patients. The initial values for the MTAC creatinine were similar in both groups. Conclusions The presenting symptoms of PS were bowel obstruction, ascites, and blood-stained effluent, often in combination with loss of net ultrafiltration. Peritoneal sclerosis is a complication of long-duration PD and could also become manifest after a successful renal transplant. Treatment should be conservative unless complications require surgical intervention. Patients with PS had lower net ultrafiltration and higher transport rates compared to controls who were matched for duration of PD. Although peritonitis incidence was similar, a relation of PS with severe peritonitis may be present in some patients. Glucose exposure is likely to be an important risk factor for PS.

Risk Factors for Encapsulating Peritoneal Sclerosis in Long‐Term Peritoneal Dialysis: A Retrospective Observational Study

“…The pathophysiology of EPS is largely unknown, but several factors, such as long-term PD, high dialysate/ plasma creatinine ratio (D/P Cr), high serum beta-2 microglobulin (b2MG), PD-associated peritonitis and the effects on the peritoneal membranes of exposure to non-physiological levels of glucose and pH, have been suggested to predispose patients to devel-oping EPS (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13). Among these etiological factors, the duration of PD therapy is thought to be the most important risk for developing EPS (1,(13)(14)(15). One study from Australia assessed the effect of increasing duration of PD on the prevalence of EPS, and found that EPS increased with the duration of PD from 1.9% for patients on dialysis >2 years to 6.4%, 10.8% and 19.4% in patients on PD for greater than 5, 6 and 8 years, respectively (1).…”

Fluid Management and Cardiovascular Outcome in Peritoneal Dialysis Patients

“…Initially, the ease with which UF could be achieved with the frequent use of 3.86% glucose exchanges led to the myth that fluid balance could be better achieved on CAPD than on hemodialysis (HD) and that ad libitum fluid intake may be possible. It is now accepted that this is not so and that excessive glucose use and exposure may lead to membrane damage and loss of UF (37). In this retrospective analysis, patients with peritoneal sclerosis had a greater cumulative glucose exposure than did their controls matched for duration of dialysis.…”

“…The evidence that increased glucose use leads to membrane failure is both direct and indirect. The pathogenetic role for glucose in the development of peritoneal sclerosis was suggested in a case-controlled study in which CAPD patients with sclerosis had a greater cumulative glucose exposure than did the controls matched for duration of CAPD, the difference being present during the first year in the majority (37). Further indirect evidence comes from the same group.…”

Opinion: What Are the Problems with Using the Peritoneal Membrane for Long‐Term Dialysis?

“…Although the evidence is principally circumstantial, there has been a general consensus in the PD community that ''glucose-sparing'' regimens need to be used to protect the long-term health of the peritoneal membrane. Although an association between the use of more hypertonic dialysate and the subsequent development of ultrafiltration failure and encapsulating peritoneal sclerosis has been proposed (20), it is difficult to dissociate cause and effect. In other words, patients who are inflamed and rapid transporters from the outset would need to use more hypertonic dialysis fluid, and they are also the same patients at risk for ultrafiltration failure and membrane alterations independent of the exposure to glucose and GDPs.…”