Chronic PD can be complicated by EPS, which is considered the most severe complication associated with long-term PD [
12]. It is not clear why some individuals develop EPS, but chronic exposure of the peritoneum to PD fluids is thought to provoke activation of various inflammatory, fibrogenic, and angiogenic cytokines that eventually lead to progressive peritoneal fibrosis, vasculopathy, and calcification [
17]. There is growing interest in this area in adult CPD patients, particularly in the incidence, risk factors, treatment, and outcome of EPS [
12,
18]. Due to the rarity of EPS, there are few reports of end-stage renal failure in children receiving CPD, and most evidence is anecdotal [
19]. Some recommend that patients with impaired peritoneal ultrafiltration or peritoneal calcification on PD for more than 5 years should be carefully managed as presumptive cases of sclerosing encapsulating peritonitis (SEP) [
20]. Some studies have shown that longer duration of PD is associated with a higher incidence of SEP. Therefore, the duration of PD is considered an important risk factor for SEP [
20]. Araki
et al. performed peritoneal biopsies in 14 children who had received PD for more than 5 years and found that 6 had simple sclerosis, while the others showed severe peritoneal sclerosis. The authors concluded that peritoneal biopsy should be performed if a patient receives PD for more than 5 years with poor UF and peritoneal calcifications on computed tomography scan [
21]. Our case developed EPS after receiving PD for less than 3 years. Infections and growth failure are major problems in pediatric patients on chronic PD and have been extensively studied, while few data are available concerning the occurrence of EPS in this age group. Previous studies have suggested that PD-related peritonitis may predispose to EPS, mostly if is recurrent or caused by
Staphylococcus aureus, fungi, or
Pseudomonas aeruginosa [
22]. The number of times a patient had peritonitis did not seem to represent itself a risk factor for EPS, whereas a single severe acute episode of peritonitis may be sufficient to activate the EPS pathophysiological cascade in an already impaired peritoneal membrane [
8]. The European Paediatric Dialysis Working Group (EPDWG) study found that children with EPS had peritonitis episodes more frequently than all other PD patients [
5], but this association was not found in an Italian study [
12] in which the overall incidence of peritonitis was not significantly different from that in children from the same registry who did not develop EPS [
6]. Our patient experienced several cases of peritonitis while she received PD, which could be a risk factor for EPS. Historically, the type of PD solution used is another important factor for EPS [
6]. Nakao
et al. concluded that use of biocompatible PD fluid contributed to a decrease in EPS development [
23]. UF failure is mainly caused by a large vascular surface of peritoneal membrane that leads to an increased permeability (dialysate-to-creatinine plasma ratio > 0.80) and faster glucose absorption. This can result in a requirement for high dialysate glucose concentrations that can further worsen both the peritoneal membrane structure and function [
24]. Interestingly, the EPDWG and Italian studies found no difference in EPS prevalence based on exposure to conventional compared with newer “biocompatible” dialysate, which is bicarbonate-based and has a lower glucose degradation product (GDP) [
5,
12]. EPS may occur during treatment with CPD after a patient switches to HD or following kidney transplantation. Posttransplantation EPS occurs with increasing frequency in adults [
12,
25]. The Japanese Ministry of Welfare working group proposed steroids as a potential therapy for EPS, leading to their widespread use in Japan. A report from one unit in Japan suggested an improvement in survival following introduction of steroids for treatment of EPS [
26]. A large recent UK series showed no difference in outcomes for patients treated with steroids,immunosuppressants, tamoxifen, or combinations of these compared with patients who did not receive treatment [
4]. Any beneficial effects of steroids are most likely to occur at an earlier, inflammatory stage of the disease [
6]. There is interest in the use of tamoxifen in EPS based on its effectiveness in other fibrotic conditions as well as case reports and small series suggesting its therapeutic benefits in EPS. Tamoxifen avoids the catabolic and immunosuppressive effects of corticosteroids and other immunosuppressant in conditions in which malnutrition and sepsis are important determinants of mortality [
27,
28]. We were unable to use immunosuppressive medication in our case because of recurrent infection during the hard treatment course, and the only management was surgical intervention and optimization of nutritional status by TPN that lasted around 6 months. The rationality for not giving tamoxifen is that there is no strong evidence to give tamoxifen in EPS , particularly in pediatric patients .In experienced hands, surgery results in high rates of improvement in symptoms and survival. Surgery should be performed in a setting in which the surgical team has experience with and understands the condition, and has appropriate perioperative renal and intensive care support [
3]. In severe cases, and cases with degrees of bowel obstruction, parenteral nutrition is usually essential [
3].
In conclusion, SEP is a rare but severe complication of PD. A high index of suspicion is required to diagnose EPS earlier. Malnutrition is a major problem in patients with severe EPS, and appropriate nutritional support with enteral or parenteral nutrition is required. Surgery is important in the management of SEP as well as optimization of growth and treating infections to achieve better prognosis.