There are several nutritional abnormalities in the peritoneal dialysis patient (PD).1 But there are not recommendations from clinical guidelines2,3 or systematic reviews4 regarding enteropathies as the cause on malabsorption and malnutrition in these patients.

We present a patient, 49 years old on PD because IgM nephropathy, with severe diarrhea with hypoalbuminemia and progressive weight loss.

Endoscopies and intestinal transit with barium were normal. Abdominal computer tomography revealed mesenteric adenopathies although the biopsy showed reactive lymphoid tissue without evidence of malignancy.

Clinically, the patient progressively deteriorated with signs of marked malnutrition and requiring regular blood transfusion to control the anemia. Then it was decide to perform an endoscopy of small intestine using a video capsule. It was observed a diffuse thickening of the intestinal wall with lymphangiectasia wide areas of ulcers, narrowing and bleeding spots (Fig. 1a and 1b). Next, biopsies were obtained that were informed as non-specific inflammation and lymphangiectasia. A new endoscopy with biopsies led to similar results.

Fig. 1.

Endoscopic evaluation using videocapsule showing diffuse thickening of intestinal folds, intense lymphangiectasia and a nodular mucosa with multiple ulcers.

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The diagnosis was entheropathy related to PD, and the patient was transferred to hemodialysis. During the following weeks, the patient improved significantly, gained weight and did not require additional blood transfusions. Six months later an additional endoscopy revealed significant healing of the intestinal mucosa. Presently the patient is in the waiting list for renal transplantation.

Enteropathy causing loss of protein in PD patients is infrequent and it is not well recognized. There are only few reports in the literature.5,6 The pathophysiological theory is that long term changes in the peritoneal membrane could result in obstruction of the lymphatic drainage; the lymphangiectasia would be the main responsible for the protein losing enteropathy.7 The treatment would be switching to hemodialysis.

In our case there were severe clinical consequences that forced multiple exploratory intervention among other the enteroscopy with viedeocapsule using the technique of double balloon. It is likely that this type of entheropathy may play a role in the suboptimal nutritional status of some PD patients. So it should be suspected if biochemistry is altered even if the patient is asymptomatic. We suggest to perform endoscopy with videocapsule in PD patients with hypoalbuminemia, anemia and unjustified weight loss.