Introduction:
Icodextrin, a starch-based glucose polymer, has been used as an alternative osmotic agent to glucose for the long dwell in patients on peritoneal dialysis (PD), enhancing fluid removal while avoiding use of hypertonic glucose. Experience with icodextrin use in children on long-term PD is limited. We describe international icodextrin prescription practices and their impact on clinical outcomes.
Methods:
Icodextrin was prescribed in 724 (20.3%) of 3573 patients enrolled in the International Pediatric Peritoneal Dialysis Network (IPPN) Registry between 2007-2024. Volume status, technique survival and peritonitis rates were assessed in 295 patients following icodextrin use for >6 months. Icodextrin users vs those receiving glucose-based dialysate only (glucose-users) were propensity score matched based on demographics, world region, disease etiology , urine output, and dialysis vintage. Outcomes of early (within 1 yr of PD start) vs. late (>1 yr) icodextrin initiation were analyzed.
Results:
Icodextrin use varied widely across world regions, ranging from 61% in Western Europe, 21% in East and Central Europe, 17% in Asia and 11% in North America. Icodextrin use was associated with older age, glomerular disease, longer dialysis vintage, lower residual kidney function, and higher membrane transport characteristics (all P<0.001).
At the time of starting icodextrin, 116 late-starters (2.32 [1.40 to 3.47] years after PD initiation) were significantly stunted, had lower serum albumin, higher PTH, higher phosphate-binder and lower diuretic use (P<0.001 for all), compared to 179 early-starters (0.15 [0.09 to 0.52] yeas). After a median 18-months of icodextrin use, ‘late-starters” relative to “early-starters” had more uncontrolled hypertension (38% vs. 20%; P<0.001), a higher anti-hypertensive agent requirement (68% vs. 55%; P=0.03) and an increase in glucose exposure from baseline (5.4 vs. 4.8 gm/kg/day; P=0.05).
Both early and late icodextrin start showed positive linear relationships with ultrafiltration adjusted for body surface area compared to glucose use during follow-up (ꞵ=0.27 and ꞵ=0.33 for early and late-icodextrin start; P=<0.01 for both). Early icodextrin use was associated with a significant decline in diastolic BP-SDS (ꞵ=-1.31, P<0.001) and a slower decline in residual kidney function (ꞵ=0.11, P=0.002) compared to glucose use; this relationship was not observed in late-starters. Peritonitis rates were similar between icodextrin and glucose groups. The slopes of ultrafiltration (adjusted to BSA) and diastolic blood pressure were comparable in children under 5 (n=76; 25.8% of the cohort) and 5 years of age and above.
Late-starters had an increased risk of technique failure/death compared to early-starters (HR 5.16, 95% CI 1.57 to 17.0; P=0.007; Figure). Causes of technique failure in were ultrafiltration failure (n=4 in late- vs. n=1 in early-starters), peritonitis (n=7 in late- vs n=6 in early-starters) and adhesions (n=1, early-starters).
Conclusions:
Icodextrin was independently associated with a sustained increase in ultrafiltration and improved volume status compared to glucose-based dialysis in all age-groups. An early start of icodextrin use conferred a greater than 5-fold higher likelihood of technique survival and better preservation of residual kidney function compared to late start of icodextrin.
I have no potential conflict of interest to disclose.
I did not use generative AI and AI-assisted technologies in the writing process.