EPS is a rare complication of PD that is characterized : intraperitoneal inflammation Fibrosis EPS causes ultrafiltration failure and bowel obstruction and is associated with significant morbidity and a high mortality.

1. mTOR inhibitors for management of
encapsulating peritoneal sclerosis
Dr Nahid Rahimzadeh
Ped Nephrologist
Rasoul-e-Akram hospital (IUMS)

2. Introduction
• EPS is a rare complication of PD that is characterized :
• intraperitoneal inflammation
• Fibrosis
• EPS causes ultrafiltration failure and bowel obstruction and is associated
with significant morbidity and a high mortality.

3. • Signs of peritoneal fibrosis are detected in 50% to 80% of patients within
one to two years on PD.
• The frequency of EPS varies across the globe between 0.5% to 7.3% , but
may be as high as 17.2% in patients undergoing PD for 15 or more years.
• The clinical presentation and diagnosis of EPS differ among centers,
countries, and over time.
• EPS may even develop after PD discontinuation, i.e., in patients who have
switched to hemodialysis (HD) or have undergone kidney transplantation

4. • The risk of EPS may be higher among transplant recipients who used to be on
peritoneal dialysis compared with patients who are still on peritoneal dialysis
and have not received a transplant.
• The reasons for the transplantation-associated risk are not known.
• The increased risk may be related to:
• the cessation of dialysis
• calcineurin inhibitors
• EPS is not a contraindication to transplantation

5. • PostTx-EPS occurs in patients with a previous history of PD in the first to
second post-transplantation year.
• At the present time almost 50 % of all EPS cases are PostTx-EPS.

6. Pathophysiology

7. Risk Factors
• Time on peritoneal dialysis
• Severe peritonitis
• Specific dialysate fluids
• Specific drugs
• Disinfectants (e.g., chlorhexidine, povidone iodine)
• Decreased ultrafiltration and increased solute transport

8. Clinical Features
• Early(inflammatory) :
• Anorexia, nausea, diarrhea, and intermittent abdominal pain.
• The physical exam is often unrevealing in early stages, may show evidence of volume
overload including weight gain and edema
• Late(ileus):
• Ileus and/or peritoneal adhesions, symptoms of intermittent obstruction( including
severe cramping, abdominal pain, constipation, and vomiting).
• The exam may reveal an abdominal mass

9. Laboratory findings
• There are no routine laboratory findings that suggest EPS.
• The peritoneal dialysis fluid may show WBCs
• Serial peritoneal equilibration tests may show a trend toward increased solute transport and
decreased ultrafiltration
• Radiographic findings
• CT scan shows peritoneal calcification, bowel thickening, tethering, and dilatation.
• Bowel tethering and peritoneal calcification are the most specific findings

10. Diagnosis of EPS
• Gastrointestinal obstruction with severe abdominal pain
• Nausea and vomiting
• Weight loss
• The transporter status is high in peritoneal equilibration tests

11. Cont
• Macroscopic inspection and/or radiological studies :
• peritoneal sclerosis
• calcified peritoneal thickening
• encapsulation of the intestine

12. Treatment
• The treatment of EPS is still controversial but is most often proposed to be
a combination of:
• Cessation of PD
• Use of immunosuppressive
• Antifibrotic agents
• Nutritional support

13. Treatment of EPS

20. Adv perit Dial 2008;24:104-10.

21. In conclusion
• The risk of EPS development is very high in patients with a history of more than 5 years of
PD treatment, frequent peritonitis episodes and alteration of PD efficacy.
• In all forms, EPS is a serious, sometimes life-threatening condition.
• If not accurately and early diagnosed and treated, EPS can severely affect the patients’
survival.
• The use of mTORi in the EPS classical form must be carefully evaluated, taking into
consideration the possibility of adverse effects in patients who do not need
immunosuppressive treatment.

22. • The best medical treatment for PostTxEPS is still controversial.
• mTORi may represent a useful option in PostTx-EPS treatment.
• Post-transplantation immunosuppressive protocol based on mTORi, MMF
and steroids, avoiding or reducing the profibrotic drugs (CNI), in order to
prevent PostTx-EPS development