Corticosteroid and tamoxifen therapy in sclerosing encapsulating peritonitis in a patient on continuous ambulatory peritoneal dialysis

Sir,

Sclerosing encapsulating peritonitis (SEP) is a clinical syndrome associated with ileus symptoms and irreversible sclerosis of the peritoneal membrane [1–4]. There is no evidence-based therapy for SEP [2]. Current suggestions include anti-inflammatory and immuno-suppressive drugs [2–7]. We report here a case of SEP, presenting with refractory peritonitis and severe abdominal symptoms.

Case. A 29-year-old woman developed end-stage renal disease secondary to reflux nephropathy in 1992. She was started on haemodialysis and was subsequently transferred to continuous ambulatory peritoneal dialysis. She was hospitalized with high fever, abdominal pain and turbid dialysate. Despite vancomycine and amikacine, she remained unwell. She was then switched back to haemodialysis. Abdominal tomography was diagnostic for SEP showing enlarged small bowel loops with an increase of peritoneal thickness. She underwent laparotomy and biopsies were taken from the peritoneum. Pathological examination confirmed the clinical diagnosis of SEP. The patient was given tamoxifen 10 mg/day and prednisolone 0.5 mg/kg/day. Her symptoms improved gradually over 2 months with an increase of serum albumin and body weight.

Chlorhexidine gluconate in alcohol, a cleanser for the peritoneal dialysis catheter, is responsible for the development of SEP [1,6,8]. Glucose-based dialysis solutions, recurrent peritonitis attacks, plasticizers and particles may also be aetiological factors [6]. The diagnosis of SEP is generally made on a peritoneal biopsy. The mortality rate was up to 43.5% [9]. The initial step in therapy should be the cessation of peritoneal dialysis [2]. Therapy with corticosteroids is effective in patients with SEP, and steroid therapy should be considered as the first line therapy [4]. Tamoxifen, a non-steroidal anti-oestrogen drug, has been successfully used in the treatment of fibrosclerotic disorders [3,10]. Transforming growth factor ß1 (TGF-ß1) has a stimulatory effect on metalloproteinases-2 and -9 (MMP2 and MMP9) [11]. Since MMP9 degrades type IV and denaturated collagens, TGF-ß1, production of which is stimulated by tamoxifen, might favour mesothelial healing by facilitating the removal of denaturated collagen. In conclusion, SEP is no more a fatal complication if peritoneal dialysis treatment is interrupted promptly, and if immunosupressive agents are administered.

Conflict of interest statement. None declared.

T. Rifki Evrenkaya, Enes M. Atasoyu, Suat Unver, Cinar Basekim, Huseyin Baloglu and M. Yasar Tulbek

Gulhane Military Medical Academy Haydarpasa Training Hospital Departments of Nephrology, Pathology and Radiology Uskudar Istanbul Turkey Email: trevrenkaya{at}ixir.com or trevrenkaya{at}turk.net

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