Peritoneal Dialysis and Encapsulating Peritonitis

Copyright © 2012 by American Roentgen Ray Society
Sclerosing encapsulating peritonitis.

Peritoneal dialysis relies on the peritoneal lining as a surface for the exchange of substances during dialysis. However the peritoneal membrane was never intended to be used for this purpose. The goal of peritoneal dialysis research is to find the least traumatic and disruptive method of ensuring efficient dialysis occurs for as long as possible before the peritoneal lining is "worn out". The greatest advance in this area would entail some method that allows the membrane to continue to function indefinitely.

One of the unsolved problems remains the absence of any clear way to predict the peritoneal membrane will react under the same circumstances from patient to patient. For instance some patients are able to withstand recurrent infections with very little structural alterations to the peritoneum while others have to be switched to hemodialysis  after one or two episodes of peritonitis.

Arguably the most feared complication of PD is an entity known as encapsulating peritoneal sclerosis (EPS) or sclerosing encapsulating peritonitis. This condition is multifactorial and thankfully quite rare with dialysis induced EPS being rarer still.



Identifiable causes include

• Post surgical.


• Medication with Beta blockers.


• Cirrhosis with ascites.


• Generalized Peritonitis of any cause.


• Peritoneal dialysis.

Encapsulating peritoneal sclerosis is characterized by inflammation of the peritoneal lining with progressive scarring and shrinking of the area of the peritoneum, since the peritoneum surrounds the intestines the intestines are slowly compressed into a tight mass of tissue surrounding by strong fibrotic bands.

Because the bowel is now packed into a very small space obstruction of the bowel becomes more common. Symptoms include abdominal pain and retention of fluid in the abdomen.

The etiologies of EPS secondary to PD include

• severe and/or nonresolving peritonitis, especially that due to Staphylococcus aureus, fungi, and Pseudomonas sp, and especially in the long-term patient.

• Increased duration of PD has been assumed by some to be a risk factor for EPS.

• Acetate-buffered PD solutions


• certain β-blocking agents


• the use of in-line bacterial filters


• exposure to certain antiseptics or disinfectants. (chlorhexidine)

It is noted by Perl Bargman and Chan that "in more than half the patients who develop EPS, the diagnosis is made after transfer to hemodialysis (HD)."

It is therefore necessary to maintain a heightened state of suspicion for this condition in patients who have peritoneal membrane failure and have to be transferred to HD. Be particularly suspicious if unexplained gastrointestinal signs occur such as abdominal pain intermittent obstruction and ascites.

The earlier the diagnosis is made the better the outcome. Antiinflammatory medications may be helpful in the early stages later on surgical therapy with nutritional support at a centre that is specialized in this condition is required.