Board question: PD-1 answer

The best answer is E. Encapsulating sclerosing peritonitis (ESP)

This patient presented with true UF failure (<400cc UF volume on a 4hr PET using 4.25% with 2L dwell volume- "rule of 4's").

The differential diagnosis of true UF failure can be separated by PET results:

Decreased D/P Cr

1. Encapsulating Sclerosing Peritonitis (ESP)
2. Adhesions
   

Stable D/P Cr

1. Increased lymphatic absorption
2. Dialysate leak
3. Catheter Malposition
4. Decreased Transcellular Transport
   

Increased D/P Cr

1. Peritonitis
2. High transport status
   

ESP is a progressive, intra-abdominal, inflammatory process that results in layers of fibrous tissue that encapsulate the viscera, thereby compromising the motility and function of the bowel. The length of time on PD is the most important risk factor for ESP, ie, the more time on PD, the greater likelihood of developing ESP. Also, high transporters may be at heightened risk for ESP compared to low or average transporters.
The presentation of ESP may include:

The CT abdomen/pelvis shows dense sheets of fibrous material in the peritoneum.

The diagnosis of ESP mandates the immediate cessation of PD. Surgery is very challenging and is usually not recommended. Steroids and tamoxifen have shown some efficacy in case studies, but this has not been systematically studied. Nutritional support with TPN is often necessary.

Michael Lattanzio DO

*RFN board questions are meant to help introduce concepts about nephrology related diseases and do not represent actual questions seen on the ABIM exam.