title: Post-transplantation encapsulating peritoneal sclerosis in a pediatric patient.
abstract: BACKGROUND
  Encapsulating peritoneal sclerosis (EPS) is a serious complication of long-term peritoneal dialysis (PD), but only a few cases have been described in the pediatric patient population. There is no established medical treatment, and surgery has been reported with variable success. The number of reports of EPS being successfully treated with tamoxifen, based on its anti-fibrotic effects, are increasing. The role of sirolimus, an mTOR inhibitor with immunomodulatory and anti-proliferative properties, has been less well-defined.
  
  
  METHODS
  A 17-year-old kidney transplant recipient, with a previous cumulative time on PD of 8 years and 3 months, developed severe bowel obstruction 8 months after undergoing a second kidney graft. Her immunosuppressive regimen consisted of tacrolimus, mycophenolate mofetil, and prednisolone. The patient underwent laparotomy, which revealed multiple thick leathery adhesions with an encapsulated small bowel. Enterolysis was performed, and total parenteral nutrition was commenced after surgery to provide an adequate food intake. Treatment with tamoxifen was initiated, but the patient developed significant liver toxicity 2 weeks later, and the drug was withdrawn. The immunosuppressive regimen was changed to an increased dose of prednisolone, and tacrolimus was replaced with sirolimos. At 20 months of follow-up, the patient remains symptom-free, with a functioning kidney transplant.
  
  
  CONCLUSIONS
  Although EPS is a very rare condition in the pediatric population, it should be considered when a child or adolescent with a long-term history of PD presents with nonspecific gastrointestinal symptoms or with signs of bowel obstruction. There is an urgent need for alternative immunosuppressive protocols. The use of sirolimus in this group of patients remains controversial.
authors.affiliation: Nephrology Department, Hospital Maria Pia, Centro Hospitalar do Porto, Rua da Boavista, 4050-111, Porto, Portugal. nicolemad@gmail.com
authors.forename: Nicole
authors.initials: N
authors.lastname: da Silva
authors.forename: Sofia
authors.initials: S
authors.lastname: Rocha
authors.forename: Liliana
authors.initials: L
authors.lastname: Rocha
authors.forename: Sameiro
authors.initials: S
authors.lastname: Faria
authors.forename: Teresa
authors.initials: T
authors.lastname: Costa
authors.forename: Conceição
authors.initials: C
authors.lastname: Mota
mesh_terms: D000293:Adolescent; D005260:Female; D006801:Humans; D016867:Immunocompromised Host; D007166:Immunosuppressive Agents / Q000009:adverse effects*; D016030:Kidney Transplantation; D009173:Mycophenolic Acid / Q000009:adverse effects / Q000031:analogs & derivatives; D010530:Peritoneal Dialysis / Q000009:adverse effects; D056627:Peritoneal Fibrosis / Q000209:etiology / Q000276:immunology* / Q000473:pathology; D011183:Postoperative Complications / Q000209:etiology* / Q000276:immunology / Q000473:pathology; D011239:Prednisolone / Q000009:adverse effects; D020123:Sirolimus / Q000009:adverse effects; D016559:Tacrolimus / Q000009:adverse effects
chemical_list: D007166:Immunosuppressive Agents; D011239:Prednisolone; D009173:Mycophenolic Acid; D020123:Sirolimus; D016559:Tacrolimus