A worrying thought—could there be a connection between encapsulating peritoneal sclerosis, tamoxifen and calciphylaxis?

Encapsulating peritoneal sclerosis (EPS) is a serious problem for chronically dialysed patients [1,2]. With an overall prevalence of 2–3% in patients undergoing peritoneal dialysis (PD), it is now obvious that extended duration of PD therapy increases the incidence and severity of EPS [3]. Mortality rates in patients with EPS remain high—especially after bowel obstruction becomes an overt problem, although success with intra-abdominal surgery is no longer a far-fetched option [2,4]. Pharmacological therapeutic choices are based on anecdotal evidence alone, but a combination of prednisone and tamoxifen has been used in an attempt to reduce both the inflammatory and fibrotic changes associated with this disease [2,5]. Tamoxifen was originally used in desmoid tumours, and since then the drug has proved to be of value in other fibroproliferative disorders, such as retroperitoneal fibrosis and Dupuytren’s contracture [6]. However, tamoxifen produces oestrogenic-like effects on certain tissues, and can lead to an increased incidence of venous thromboembolism [7]. Over the last year, we treated two patients with advanced EPS, with prednisone and tamoxifen. Both developed overwhelming, and ultimately fatal, calciphylaxis. Their case reports follow, together with a discussion on the possible role of tamoxifen in initiating calciphylaxis—a condition characterized by the presence of intraluminal thrombi in small calcified blood vessels of the dermis [8]. Some precautionary measures that can be undertaken before commencing tamoxifen in patients with EPS are given. Case 1