C-reactive protein levels in combination with abdominal CT scans is a useful tool to predict the macroscopic appearance in late-stage EPS patients prior to surgery

Figures & data

Table 1 CT scan scoring system by Tarzi et al

Peritoneal calcification	Score
Not identified	0
Localized area <20%	1
>20% of peritoneum	2
>50% of peritoneum	3
Extensive >80%	4
Bowel tethering
Not present	0
Mild tethering	1
Moderate tethering	2
Marked tethering	3
Peritoneal thickening
Not identified	0
Localized area <20%	1
>20% of peritoneum	2
>50% of peritoneum	3
Extensive >80%	4
Loculation
Not present	0
<3 locules	1
3–6 locules	2
Multiloculated	3
Bowel wall thickening
Not identified	0
Localized bowel	1
>20% of bowel	2
>50% of bowel	3
Extensive >80%	4
Bowel dilatation
Not identified	0
Localized bowel	1
>20% of bowel	2
>50% of bowel	3
Extensive >80%	4

Notes: The maximum score is 22, and scores >2.5 are abnormal. CT scan scoring system by Tarzi et al.²⁸

Abbreviation: CT, computed tomography.

Table 2 Cut-off values for a positive CT scan, using the CT scan scoring parameters of Vlijm et al

Item	Positive/negative
Peritoneal thickening
Peritoneal calcification
Peritoneal enhancement
Adhesions of bowel loops
Signs of bowel obstruction
Fluid loculation/septation

Notes: Every item is scored as positive or negative. Three of six items are required for a contrast-enhanced CT scan, and two of five items when no contrast enhancement is used. Cut-off values for a positive CT scan, using the CT scan scoring parameters of Vlijm et al.²⁹

Abbreviation: CT, computed tomography.

Table 3 Clinical data of study population

Variable	Patients with late-stage EPS
Total number of patients	30
Age (years ± SD)	52.3±11.8
Female/male	6/24
Clinical criteria (Nakamoto^Citation14) fulfilled	30/30
PD duration at time of surgery (months) (IQR)	73 (57.8–106.5)
PET at diagnosis of EPS
Low/low average	6/30
High average/high	24/30
Daily urine output (mL) (IQR)	0.0 (0.0–495.0)
Peritonitis	59 in 2,573 months; 1:44
Icodextrin	25/30
Diabetes	7/30
Smoking	9/30
Hypertension	27/30
Hemoglobin (g/dL ± SD) (range; normal 13–18)	11.1±2.1
Hematocrit ± SD	0.3±0.1
Leukocytes (×10^9/L ± SD) (range; normal 4.0–11.3)	8.6±5.2
CRP (mg/dL, 0.1–0.5) (IQR)	2.6 (1.3–9.6)
Phosphate (mmol/L) (range; normal 0.68–1.68)	1.3±0.9
Calcium (mmol/L ± SD) (range; normal 1.90–2.70)	2.2±0.3
PTH (pmol/L) (range; normal 1.1–7.3)	20.5 (5.1–40.1)
Urea-N (mg/dL ± SD) (range; normal 10–25)	81.3±35.3
Creatinine (mg/dL ± SD) (range; normal 0.5–1.4)	6.7±2.5
ICU stay (days) ± SD	9.6±7.0
Hospitalization (days) ± SD	36.8±24.3
cEPS	23/30
PT-EPS	7/30
Body mass index at time of surgery ± SD	20.7±2.8
Time between cessation of PD and surgery (months),	10 (2–23)
median (IQR)
Time from onset of symptoms to surgery (months), median (IQR)	4.5 (1.0–11.3)
Operation time (minutes) ± SD
Type Ia	365±86.6.3
Type II	346±117.82
Type IIIa	288±81.1
Intestinal anastomosis during surgery due abdominal mass
Type I	1/9*
Type II	3/6*
Type III	5/15*
Suturing of serosa defects or anastomosis due to bowel injury
Type Ib	7/9*
Type II	0/6*
Type III	0/15*
Reoperation after PEEL
Type Ia	4/9*
Type II	0/6*
Type III	1/15*
Alive/dead at the time of follow-up	21/9
(median 28.5 months; range, 3.8–62.5)
Death after surgery (during hospital stay)
All patients	3/30
Type I	2/9*
Type II	1/6*
Type III	0/15*
Reoperation because of recurrent EPS	3/30
Alive/dead at the time of follow-up (median 28.5 months; range, 3.8–62.5)	21/9
Death after surgery	3/30
Death from EPS (total)	1
Death from other causes (total)	5
Corticosteroid therapy prior to surgery	6/30
Tamoxifen therapy prior to surgery	2/30
ASA class ± SD	3±0.5

Notes:

* The first number (shown before “/”) indicates the number of patients with the noted variable, the second number (shown after “/”) indicates the number of patients with EPS Type I, Type II, or Type III, respectively.

a P<0.05,

b P<0.001. EPS commonly presents after peritoneal dialysis has been stopped, either PT-EPS or after switching to hemodialysis (cEPS).

Abbreviations: SD, standard deviation; PD, peritoneal dialysis; IQR, interquartile range; PET, peritoneal equilibrium test; CRP, C-reactive protein; PTH, parathyroid hormone; ICU, intensive care unit; PEEL, peritonectomy and enterolysis; ASA, American Society of Anesthesiologists; EPS, encapsulating peritoneal sclerosis; PT-EPS, post-transplantation EPS; cEPS, classical EPS.

Figure 1 Cross-sectional abdominal CT images of EPS Type I–III patients.

Notes: In EPS Type I (A–D), only mild peritoneal calcification (thin arrows in B), extensive loculated ascites (thick arrows in A–D), air entrapment in ascites (thick arrow in D, no intestinal perforation was detected during PEEL surgery), and adhesions of bowel loops with bowel wall thickening and dilatation are observed (A). CM enhancement of the peritoneum (thin arrows in C). EPS Type II (E–F) is showing adhesions of bowel loops with bowel wall thickening and dilatation (thick arrow in E) and loculated ascites (thin arrows in E), bowel tethering (thick arrow in F) and bowel dilatation (thin arrow in F). In EPS Type III (G–I), extensive calcification of the peritoneal membrane (G and H), including free-flowing ascites (thick arrows in G and H), and extensive peritoneal thickening (thin arrows in I) exist.
Abbreviations: CT, computed tomography; EPS, encapsulating peritoneal sclerosis; PEEL, peritonectomy and enterolysis; CM, contrast medium.

Table 4 Results of the CT scoring system in our study population using both established CT scoring systems

Variable	Patients with EPS (n=30)
CT scoring system by Tarzi et al^Citation28 (IQR)	11 (8–12)
CT scoring system by Tarzi et al^Citation28>2.5	30/30
CT scoring system by Vlijm et al^Citation29
CM-enhanced CT scan	4±1
Native CT scan	4±1
CT scoring system by Vlijm et al^Citation29
CM-enhanced CT ≥3/6	22/22
Native CT Scan ≥2/5	8/8

Abbreviations: CT, computed tomography; IQR, interquartile range; CM, contrast medium; EPS, encapsulating peritoneal sclerosis.

Table 5 CT findings in different macroscopic phenotypes of EPS (n=30)

Findings	Type I (n=9)	Type II (n=6)	Type III (n=15)
Peritoneal thickening	9	5	15
Peritoneal calcification	2c,h	0d,i	11
Peritoneal CM enhancementb	4	2	3
Fluid loculation/septation	9e,i	6f,h	10
Adhesions of bowel loopsb	5g,h	3	14
Bowel wall thickeninga	5	6	15
Bowel dilatationa	6	5	14
Bowel tetheringa	9	5	15
Signs of bowel obstructionb	6	5	14

Notes:

a Item used only in the scoring system by Tarzi et al;²⁸

b item is used only in the scoring system by Vlijm et al;²⁹

c Type I vs Type III;

d Type II vs Type III;

e Type I vs Type III;

f Type II vs Type III;

g Type I vs Type III;

h P<0.05;

i P<0.01.

Abbreviations: CT, computed tomography; EPS, encapsulating peritoneal sclerosis; CM, contrast medium.

Figure 2 CT score of patients with different macroscopic phenotypes (mean ± SD) and CRP levels (median with IQR) in patients with EPS Type I–III.

Notes: Using the CT scoring system by Tarzi et al²⁸ (A); and the CT scoring system by Vlijm et al²⁹ (B).
Abbreviations: CT, computed tomography; SD, standard deviation; CRP, C-reactive protein; IQR, interquartile range; EPS, encapsulating peritoneal sclerosis.

Figure 3 Prediction of the macroscopic phenotype based on the CT scores

Notes: Using the CT scoring system by Vlijm et al²⁹ (A) and the CT scoring system by Tarzi et al²⁸ (B) in combination with CRP values.
Abbreviations: CT, computed tomography; CRP, C-reactive protein; EPS, encapsulating peritoneal sclerosis.

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