Jaime Manue Justo-Janeiro (fics-facs)l,2*, Elizabeth Huerta-Calixto2, de la Rosa Paredes René2, Fernando Vázquez de Lara3 and Luis G Vázquez de Laral
lFaculty of Medicine, Meritorius Autonomous University of Puebla, Mexico
2Department of Organ Transplantation, General Hospital of Puebla “Dr. Eduardo Vázquez Navarro”, Puebla, Puebla, Mexico
3Department of Internal Medicine, Icahn School of Medicine at Mount Sinai West and St. Luke’s, New York, NY, USA
Received: 09 March, 2017; Accepted: 17 May, 2017; Published: 19 May, 2017
Jaime Manuel Justo-Janeiro, Department of Organ Transplantation, General Hospital of Puebla “Dr. Eduardo Vázquez Navarro”, Puebla, Puebla, Mexico, Tel: 52 (222) 303-83-91; E-mail:
Justo-Janeiro JM, Huerta-Calixto E, de la Rosa PR, Vazquez de Lara LG, Vázquez de Lara F (2017) Encapsulating Peritoneal Sclerosis. Different Clinical Presentations and their Management. Arch Renal Dis Manag 3(1): 007-011. DOI: 10.17352/2455-5495.000019
© 2017 Justo-Janeiro JM. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Peritoneal dialysis; End Stage Renal Disease; Peritonitis
Introduction: One of most common treatments of end-stage renal disease is peritoneal dialysis. Encapsulating peritoneal sclerosis is a complication in which the osmotic capacity of the peritoneal barrier is lost, due to infections or the irritating effect of dialysis solutions. This pathology has different clinical presentations, hence the need of different diagnostic and therapeutic methods.
Objective: To present a series of three cases with encapsulating peritoneal sclerosis and different clinical pictures, using laparoscopy as the mainstay for diagnosis and treatment.
Patients and methods: This work describes the clinical and imaging features of three patients. A systematic approach was utilized which included the delimitation of the affected zone, sterilization, collapse of the cavity, and change of dialysis mode until renal transplantation.
Conclusions: Our work suggests that a laparoscopic approach to encapsulating peritoneal sclerosis can be very valuable for the diagnosis and treatment of this condition and controlled clinical trials are warranted to validate this observation
According to The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) guidelines for chronic kidney diseases, end-stage renal disease (ESRD) is defined as an irreversible decline in kidney function, characterized by a level of glomerular filtration rate (GFR) below 15 mL/min/1.73 m2 or by the need of dialysis or transplantation, regardless of the level of GFR . The etiology is diverse and age-related. In adults, diabetes (30-40%) and arterial hypertension (25-30%) are the most common causes, while in children, primary glomerulopathies and congenital abnormalities are the usual culprits .
Currently, patients with ESRD are offered peritoneal dialysis, hemodialysis or renal transplantation as renal replacement therapies [2,3]. Peritoneal dialysis is the most widely used, because it is inexpensive and can be performed in an ambulatory basis . The first description of this therapy was made by Ganter in 1923, but it was until 1976 when Popovich et al. , described the basic concepts of continuous ambulatory peritoneal dialysis (CAPD) as they are known today. Current techniques allow peritoneal fluid instillation and drainage with minimum disruption in patient’s lifestyle . This therapy utilizes the peritoneal membrane’s properties for diffusion and ultrafiltration and its effectiveness depends on the functional and structural integrity of the peritoneum. The peritoneal membrane is a complex and functional structure which is formed by a layer of mesothelial cells, connective tissue, blood vessels, lymphatic vessels and innate immune cells which can be affected by peritoneal dialysis in the long term [3,7].
Encapsulating peritoneal sclerosis (EPS) is defined by clinical and pathologic criteria, such as macroscopic honeycomb appearance, fibrin deposits, edema, mononuclear infiltration, fibroblast activation markers and fibroblast proliferation into the peritoneum [8,9]. EPS impairs the capability of the peritoneum for diffusion and dialysis and it must be suspected in any patient with evidence of ultrafiltration failure [10,11]. EPS was originally described by the International Society for Peritoneal Dialysis in patients with loss of the peritoneum osmotic capability and the diagnosis is confirmed by imaging studies. The images seen may be originated either by peritoneal abnormalities, such as liquid trilaminate appearance, organ adherence to the anterior abdominal wall, calcifications, peritoneal thickening and encapsulation ; or by small intestine abnormalities, such as abnormal peristalsis, intestinal obstruction, small intestine immobilization, liquid collections and a cocoon appearance. These findings can be seen with ultrasound, tomography or MRI. Clinically, patients may be asymptomatic or show evidence of intestinal obstruction with nausea, vomiting, abdominal distention, anorexia and weight loss, fever and an abdominal mass . There is not a widely accepted biochemical marker to diagnose EPS; however, some authors have suggested that low levels of CA125 and high concentrations of IL6 in dialysis fluid have a 70% sensitivity and 89% specificity in diagnosing EPS. Honda has proposed that a persistently elevated C reactive protein may aid in the diagnosis of EPS .
The aim of this work is to describe three clinical presentation patterns found in EPS in a clinical case format along with laparoscopy-based therapeutic options.
We present the clinical and imaging features of three different patients with EPS. A systematic decision-making process for the resolution of each case was used, which comprised of the delimitation of the affected zone, sterilization, collapse of the cavity, and change of dialysis mode until renal transplantation.
An 18 year-old male with ESRD treated with CAPD for 42 months, was considered for renal transplantation. During the physical exam, a solid and fixed 20 x 30 cm epigastric mass was found, and laparoscopic exploration was offered. Intraoperatively a sclerotic peritoneum was observed in the inferior middle part of the abdomen with the peritoneal pigtail catheter in place (Figure 1). In the upper part of the abdomen a transparent membrane with small intestine inside (Figure 2) was also found. No further treatment was necessary.