Encapsulating peritoneal sclerosis in the era of a multi-disciplinary approach based on biocompatible solutions: the NEXT-PD study

Abstract

Introduction: Encapsulating peritoneal sclerosis (EPS) is a serious complication of peritoneal dialysis (PD). Over the past decade in Japan, a multidisciplinary approach has been adopted to minimize the incidence and improve outcomes of EPS. This strategy includes planned PD discontinuation for high-risk patients and the introduction of biocompatible solutions. This study examined the current clinical status of EPS in representative PD centers in Japan.

Design, setting, participants and measurements: Patients (n = 1,338) from 55 PD centers in Japan who were using neutral-pH solutions from the initiation of therapy (mean age, 62 years; median PD duration, 32 months; concomitant use of icodextrin, 35.2%; PD and hemodialysis combination therapy, 12.2%) were assessed every 6 months to ascertain the reasons for PD discontinuation and the development of EPS development. Outcomes were also recorded. The study period was from November 2008 to March 2012.

Results: There were 727 patients who discontinued PD, including 163 deaths. Among all causes of PD withdrawal except for death, planned PD discontinuation to avoid EPS was utilized in 58 cases (7.1% in total). The strategy was increasingly utilized in proportion to the duration of PD: 0.5% for patients undergoing PD for < 3 years, 0.6% for patients undergoing PD for 5 years, 14.7% for patients undergoing PD for 8 years, and 35.5% for patients undergoing PD for > 8 years. Fourteen patients developed EPS (three cases after PD), which corresponded with an overall incidence of 1.0%. The incidence according to the duration of PD was 0.3% for PD < 3 years, 0.6% for PD = 5 years, 2.3% for PD = 8 years, and 1.2% for PD > 8 years. In terms of therapy, 11 patients were treated with prednisolone (PSL), and surgical enterolysis was utilized in two cases. Complete remission of abdominal symptoms was achieved in twelve patients (85.7%), and three died due to EPS (mortality rate of 21.4%).

Conclusions: Use of the multidisciplinary approach described above reduces the risk of the development of EPS according to PD duration. In cases of de novo EPS cases in Japan, this strategy can also attenuate the clinical course of the condition.

Keywords: Peritoneal dialysis; encapsulating peritoneal sclerosis; neutral solution.

Figure 1 —

Distribution of the number of patients according to the duration of PD. PD = peritoneal dialysis.

Figure 2 —

Reasons for PD discontinuation according to the duration of PD; cases with PD duration <3 years (a), 3 to 5 years (b), 5 to 8 years (c), and >8 years (d). Among patients who discontinued PD due to PD-related complications, catheter-related peritonitis occurred in 88.0% (66 cases) of patients with a PD duration of <3 years, 93.0% (53 cases) of patients with a PD duration of 3 to 5 years, 73.7% (28 cases) of patients with a PD duration of 5 to 8 years, and 80.0% (four cases) of patients with a PD duration of >8 years. PD = peritoneal dialysis; EPS = encapsulating peritoneal sclerosis.

Figure 3 —

Number of EPS patients, and incidence of EPS according to the duration of PD. The incidence of EPS according to the duration of PD is as follows: <3 years of PD, 0.31% (95%CI: 0.05 to 1.73); 3 to 5 years of PD, 0.55% (95%CI: 0.19 to 1.62); 5 to 8 years of PD, 2.31% (95%CI: 1.22 to 4.33); >8 years of PD, 1.20% (95%CI: 0.21 to 6.51). EPS = encapsulating peritoneal sclerosis; PD = peritoneal dialysis; CI = confidence interval.

Figure 4 —

Clinical outcomes of EPS patients (n=14) during the study period. Status 1 = normal oral intake with no presenting abdominal symptom; Status 2 = normal oral intake possible, but with presenting intermittent episodes of ileus signs; Status 3 = oral intake impossible, with presenting ileus signs. EPS = encapsulating peritoneal sclerosis; PSL = oral prednisolone.