Tseng Chin-Chung, Chen Jin-Bor, Wang I-Kuan, Liao Shang-Chih, Cheng Ben-Chung, Wu An-Bang, Chang Yu-Tzu, Hung Shih-Yuan, Huang Chiu-Ching
Division of Nephrology, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan.
Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
PLoS One. 2018 Jan 2;13(1):e0190079. doi: 10.1371/journal.pone.0190079. eCollection 2018.
Encapsulating peritoneal sclerosis (EPS) is a rare but serious complication of long-term peritoneal dialysis (PD). However, previous studies reported large variations in its mortality rates that may associate with a different degree of EPS severity. This study reports the incidence and outcomes of EPS and identifies the risk factors associated with severe EPS.
We retrospectively analyzed clinical data of EPS patients from 3 medical centers in Taiwan from January 1982 to September 2015, and classified patients as having mild/moderate or severe EPS. Patients with intractable intestinal obstruction/gut-related sepsis that needed surgical intervention or resulted in mortality were in severe EPS group. Follow-up for outcome was through December 31, 2015. Clinical characteristics, peritoneal dialysis (PD)-related parameters, biochemical and imaging results were analyzed and compared between groups.
Fifty-eight of 3202 patients undergoing PD during the study period had EPS (prevalence 1.8%). The incidence of EPS increased for patients on PD for >6-8 years (≤6 yrs. vs. >6-8 yrs., 0.0% vs. 1.8%, p = 0.001). Relative to those on PD for >6-8 years, the risk of EPS significantly increased with PD duration longer than 10 years (>10-12 years vs. >6-8 years: OR: 5.5, 95% CI: 1.7-17.1, p < 0.01). Twenty-three patients fulfilled the criteria for severe EPS. The overall mortality rate of EPS was 35% (20/58), and was 74% (17/23) in the severe EPS group. The average serum levels of C-reactive protein (CRP) and intact-parathyroid hormone (i-PTH), which were checked every 3~6 months within one year before diagnosis of EPS, were higher in severe EPS group than in mild/moderate group (p = 0.02, p = 0.08, respectively). Multivariate analysis revealed severe EPS was independently associated with bowel tethering (based on CT), presentation with bloody ascites, diagnosis of EPS after withdrawal from PD, and i-PTH ≥ 384 pg/mL. Receiver operating characteristic analysis indicated that presentation with 2 or more of the 5 risk factors (EPS diagnosis after PD withdrawal, bloody ascites, bowel tethering, CRP ≥ 29 mg/L, and i-PTH ≥ 384 pg/mL) had a good accuracy (AUC = 0.80, p = 0.001) for prediction of severe EPS.
The incidence of EPS increases with PD duration. Severe EPS has high mortality rate and is associated with bowel tethering, presentation of bloody ascites, diagnosis after PD withdrawal, and higher serum levels of i-PTH before EPS diagnosis. Having 2 or more of the 5 risk factors can provide a good accuracy for prediction of severe EPS.
包裹性腹膜硬化（EPS）是长期腹膜透析（PD）罕见但严重的并发症。然而，既往研究报道其死亡率差异很大，这可能与EPS严重程度不同有关。本研究报告了EPS的发病率和结局，并确定了与严重EPS相关的危险因素。
我们回顾性分析了1982年1月至2015年9月台湾3个医疗中心EPS患者的临床资料，并将患者分为轻度/中度或重度EPS。因顽固性肠梗阻/肠道相关败血症需要手术干预或导致死亡的患者属于重度EPS组。随访至2015年12月31日。分析并比较两组患者的临床特征、腹膜透析（PD）相关参数、生化及影像学结果。
研究期间3202例接受PD治疗的患者中有58例发生EPS（患病率1.8%）。PD治疗>6 - 8年的患者EPS发病率增加（≤6年 vs. >6 - 8年，0.0% vs. 1.8%，p = 0.001）。相对于PD治疗>6 - 8年的患者，PD持续时间超过10年时EPS风险显著增加（>10 - 12年 vs. >6 - 8年：OR：5.5，95%CI：1.7 - 17.1，p < 0.01）。23例患者符合重度EPS标准。EPS的总体死亡率为35%（20/58），重度EPS组为74%（17/23）。在诊断EPS前一年内每3~6个月检查一次的血清C反应蛋白（CRP）和全段甲状旁腺激素（i-PTH）平均水平，重度EPS组高于轻度/中度组（分别为p = 0.02，p = 0.08）。多因素分析显示，重度EPS与肠粘连（基于CT）、血性腹水表现、PD撤机后诊断EPS以及i-PTH≥384 pg/mL独立相关。受试者工作特征分析表明，出现5个危险因素中的2个或更多（PD撤机后EPS诊断、血性腹水、肠粘连、CRP≥29 mg/L和i-PTH≥384 pg/mL）对预测重度EPS具有良好的准确性（AUC = 0.80，p = 0.001）。
EPS的发病率随PD持续时间增加。重度EPS死亡率高，与肠粘连、血性腹水表现、PD撤机后诊断以及EPS诊断前较高的血清i-PTH水平相关。出现5个危险因素中的2个或更多对预测重度EPS具有良好的准确性。
