Sclerosing peritonitis after kidney transplantation - a case report

Sklerozirajući peritonitis (SP) rijetka je i po život opasna (smrtnost 30-93%) komplikacija peritonejske dijalize (PD). Javlja se u 0,6-3,3 % bolesnika na PD-u. Bubrežno presađivanje (transplantacija, TX) nakon PD-a povisuje rizik nastanka SP-a (prevalencija 7,5%). Etiopatogeneza nije jasna, a epidemiološki pokazatelji ukazuju na rizične čimbenike (PD per se, trajanje PD-a, hiperosmolarne otopine za PD, smanjenje ultrafiltracije-UF, beta blokatori- BB) od kojih neki mijenjaju citokinsku ravnotežu u potrbušnici, povisujući profibrotični transformirajući čimbenik -ß (TGF- ß). Pretpostavlja se da smanjena odteredba (engl. clearance) fibrina nakon prekida PD-a koji uslijedi nakon bubrežne TX uz imunosupresivne (IS) lijekove (od kojih kalcijneurinski inhibitori, CNI, djeluju profibrotično) povisuju rizik za SP. Klinički se javlja slika crijevne opstrukcije, a dijagnoza se potvrđuje kompjutoriziranom tomografijom trbuha (zadebljanje potrbušnice) i patohistološkim pregledom bioptata potrbušnice. Preporučuju se preventivni postupci u rizičnih bolesnika, uključivo specifičan izbor IS lijekova nakon TX. Prikazujemo slučaj bolesnice sa SP-om u prvoj godini nakon bubrežne TX. Rizični čimbenici za SP bili su PD u trajanju od 7 godina, smanjena UF, hiperosmolarne otopine za PD, bubrežna TX, beta blokatori i IS kalcijneurinskim inhibitorima. Liječenje je, uz kirurško, uključivalo isključivanje CNI i BB, uz primjenu IS mTOR inhibitorima i tamoksifen.Sclerosing peritonitis (SP) is rare and life threatening (mortality 30 93%) complication of peritoneal dialysis (PD). It appears in 0.6-3.3% of PD patients. Kidney transplantation (TX) increases the risk for SP (prevalence 7.5%). Ethiopathogenesis is unclear, while epidemiological data indicate risk factors (PD per se, long duration, hyperosmolar solutions for PD, reduced ultrafiltration-UF, beta blockers-BB) that change peritoneal cytokines equilibrium, increasing profibrotic transforming factor-ß (TGF- ß). Reduced fibrin clearance, considered to follow PD cessation, along with immunosuppressive (IS) drugs (calcineurin inhibitors, CNI, among them having profibrotic properties), increases the risk for PD after kidney TX. SP clinically resents by symptoms and signs of intestinal obstruction, and the diagnosis is being confirmed by abdominal computerized tomography, CT, (peritoneal thickening) and pathohistological analysis of peritoneal tissue. Preventive measures in the patients at risk are recommended, including specific IS after kidney TX. We present a case of a female patient with SP in the first year after kidney TX. Risk factors for SP in the patient were PD lasting for 7 years, reduced UF, hyperosmolar PD solutions, kidney TX, BB and CNI IS. The treatment, apart from surgery, included CNI and BB therapy cessation and mTOR inhibitor IS and tamoxifen introduction