Icodextrine : quels arguments pour et contre son utilisation comme agent osmotique en dialyse péritonéale ?

Icodextrin is a glucose polymer derived from starch that is used as an osmotic agent in peritoneal dialysis. Its high molecular weight limits blood absorption and is useful for long dwell since there is few osmotic gradient dispersal. Its benefits are numerous: ltrafiltration optimization and better salt and water control especially in anuric patients with a high peritoneal permeability and also in case of infectious peritonitis, glucose sparing with less metabolic complications and a better preservation of peritoneal membrane, better biocompatibility. However it should not be forgotten that icodextrin has also side effects that must be known: allergies, cases of aseptic peritonitis, overintense water and salt depletion, lymphatic absorption of icodextrin and its metabolites (including maltose) with a risk of false capillary glucose rate estimation and a moderate increase in plasma osmolality. That is why it is not recommended now to use more than one daily icodextrin dwell. Nevertheless, several dialysis units use icodextrin in more than one daily dwell, especially in patients with an important ultrafiltration loss or in those in whom glucose sparing is essential. It seems to profit them with no more side effects. A large multicenter trial is in progress to test the efficacy and safety of icodextrin dwell twice a day in elder incident patients in peritoneal dialysis (DIDo). Moreover, icodextrin is also used combined with glucose in a long dwell (bimodal ultrafiltration) with encouraging results in terms of ultrafiltration and glucose sparing.     

Comparison of icodextrin and glucose solutions for the daytime dwell in automated peritoneal dialysis.

BACKGROUND: The sustained ultrafiltration achieved by icodextrin is more suited for the daytime dwell in automated peritoneal dialysis (APD) than glucose solutions. METHODS: Seventeen patients receiving APD underwent assessment using three different solutions for the daytime dwell: 2.27% glucose, 3.86% glucose and 7.5% icodextrin. Patients were then observed on icodextrin for a 6 month period. RESULTS: Daytime ultrafiltration was greater for 3.86% glucose (median 0.10, IQR 0.01 to 0.321) P<0.01 and icodextrin (median 0.26, IQR 0.14 to 0.361) P<0.001 than 2.27% glucose (median -0.19, IQR -0.54 to -0.081), with 3.86% glucose and icodextrin not being significantly different. Positive ultrafiltration occurred in 3/17 patients with 2.27% glucose, 13/17 patients with 3.86% glucose and 16/17 patients with icodextrin (chi2 P<0.0001). The difference in ultrafiltration of icodextrin and 3.86% glucose correlated with the 4 h dialysate/plasma creatinine ratio in a PET test (r = 0.51, P<0.05). Daytime Kt/V urea was greater for 3.86% glucose (median 0.27, IQR 0.20 to 0.48 per week, P<0.01) and icodextrin (median 0.31, IQR 0.27 to 0.49 per week, P<0.0001) than for 2.27% glucose (median 0.22, IQR 0.15 to 0.38 per week), with the difference between 3.86% glucose and icodextrin not reaching statistical significance (P = 0.06). Daytime creatinine clearance was greater for 3.86% glucose (median 10.2, IQR 6.9 to 13.61/week/1.73 m2, P<0.02) and icodextrin (median 12.1, IQR 9.3 to 15.71/week/1.73 m2, P<0.005) than for 2.27% glucose (median 8.8, IQR 4.9 to 11.91/week/1.73 m2). Daytime creatinine clearance was greater for icodextrin than for 3.86% glucose (P<0.005). The effects of icodextrin were sustained for the 6 month observation period. CONCLUSIONS: Icodextrin produced enhanced ultrafiltration and clearances compared with 2.27% glucose, without the exposure of the peritoneum to hypertonic glucose solutions.     

Clinical experience with icodextrin in children: ultrafiltration profiles and metabolism

Icodextrin use in adults provides sustained ultrafiltration (UF) in long-term dwells. No information is available on UF and metabolism in children. In 11 children, a volume of 1,049±138 ml/m² of the study fluid (1.36% glucose, 7.5% icodextrin, 3.86% glucose) was administered for 12 h. Net UF with icodextrin (339±147 ml/1.73 m²) did not differ from UF with 3.86% glucose (450±306 ml/1.73 m², P=0.53) and was higher than UF with 1.36% glucose (–87±239 ml/1.73 m², P=0.003). Icodextrin added 0.52±0.07 to the weekly Kt/V. Over 6 weeks, icodextrin was used for 12-h daytime dwell. Total icodextrin reached a steady-state level of 2.91±1.22 g/l at 2 weeks. The main icodextrin metabolites were maltose, maltotriose, and maltotetraose. After 2 weeks, steady state levels were 2.02±0.66 mmol/l, 1.46±0.35 mmol/l, and 0.45±0.12 mmol/l. No icodextrin or metabolites were detectable 4 weeks after the study. We conclude that 7.5% icodextrin is capable of maintaining UF during 12-h dwell in children and is comparable to UF obtained with 3.86% glucose. Steady-state levels of icodextrin and metabolites were reached at 2 weeks and disappeared after the study. Received: 11 November 1999 / Revised: 28 March 2000 / Accepted: 29 March 2000     

Effect of peritonitis on peritoneal transport characteristics: glucose solution versus polyglucose solution

BACKGROUND: Peritonitis is a common clinical problem and contributes to the high rate of technique failure in continuous ambulatory peritoneal dialysis treatment. The present study investigated the effect of peritonitis on peritoneal fluid and solute transport characteristics using glucose and polyglucose (icodextrin) solutions. METHODS: A four-hour dwell was performed in 32 Sprague-Dawley rats (8 rats in each group), with 131I albumin as an intraperitoneal volume marker. Peritonitis was induced by an intraperitoneal injection of 2 mL lipopolysaccharide (100 microg/mL phosphate-buffered saline) four hours before the dwell. Each rat was intraperitoneally infused with 25 mL of 3.86% glucose [glucose solution control group (Gcon) and glucose solution peritonitis group (Gpts)] or 7.5% icodextrin solution [icodextrin solution control group (Pgcon) and icodextrin peritonitis group (PGpts)]. RESULTS: Net ultrafiltration was significantly lower (by 44%) in the Gpts as compared with the Gcon group, but was significantly higher (by 138%) in the PGpts as compared with the PGcon group. The peritoneal fluid absorption rate, including the direct lymphatic absorption rate, was significantly increased (by 78%) in the Gpts group as compared with the Gcon group. However, the total fluid absorption did not differ between the PGpts and the PGcon groups. The dialysate osmolality decreased much faster in the Gpts group as compared with the Gcon group, resulting in significantly lower (by 9%) transcapillary ultrafiltration in the Gpts group. In contrast, the dialysate osmolality increased faster in the PGpts group as compared with the PGcon group, resulting in higher (by 40%) transcapillary ultrafiltration in the PGpts group. The in vitro increase in dialysate osmolality was also higher in the PGpts group as compared with the PGcon group. The solute diffusive transport rates were, in general, increased in the two peritonitis groups as compared with their respective control groups. CONCLUSIONS: Our results suggest the following: (1) Peritonitis results in decreased net ultrafiltration using glucose solution caused by (a) decreased transcapillary ultrafiltration and (b) increased peritoneal fluid absorption. (2) Ultrafiltration induced by the icodextrin solution appears to be related to the increase in dialysate osmolality (mainly because of the degradation of icodextrin). (3) Peritonitis results in increased degradation of icodextrin and a faster increase in dialysate osmolality and therefore better ultrafiltration, whereas the fluid absorption rate does not change. (4) Peritonitis results in increased peritoneal diffusive permeability.     

Icodextrin instead of glucose during the daytime dwell in CCPD increases ultrafiltration and 24-h dialysate creatinine clearance

BACKGROUND AND METHODS: Icodextrin 7.5% is an iso-osmolar, glucose polymer-containing peritoneal dialysis solution with an ultrafiltration potential similar to glucose 3.86%. We compared in an open, randomized, prospective study the ultrafiltration potential of icodextrin with that of glucose during the daytime dwell of 23 patients treated with automated peritoneal dialysis (CCPD). RESULTS: Daytime ultrafiltration volume and 24-h ultrafiltration volume increased significantly in icodextrin-treated patients (n = 11) at 3 and 6 months, allowing patients a less rigid fluid restriction or an adapted treatment schedule. This improved the patients' subjective well-being. Although ultrafiltration at 9 and 12 months also increased it did not reach statistical significance. Similar to the gain in ultrafiltration volume, 24-h dialysate creatinine clearance per 1.73 m2 (DCl/1.73 m2) and DCl/1.73 m2 per litre used dialysate (DCl/1.73 m2/l) increased in icodextrin-treated patients. DCl/1.73 m2/l per litre ultrafiltrate (DCl/1.73 m2/l/UF) did not increase. No side-effects of icodextrin were encountered, although serum disaccharide levels increased. CONCLUSION: Icodextrin enhances ultrafiltration during the daytime dwell in CCPD patients. As a result of an increased 24-h ultrafiltration volume, DCl/1.73 m2 and DCl/1.73 m2/l improve. DCl/1.73 m2/l/UF does not rise, which suggests that the increase in DCl/1.73 m2 and DCl/1.73 m2/l is caused by convective transport.      

Specific characteristics of peritoneal leucocyte populations during sterile peritonitis associated with icodextrin CAPD fluids.

BACKGROUND: Icodextrin dialysate used for peritoneal dialysis contains an iso-molar glucose polymer solution, which provides sustained ultrafiltration over long dwell times and is considered a valuable approach to reduce intraperitoneal glucose exposure. However, several side effects have been described, including abdominal pain and allergic and hypersensitivity reactions. Also, reactions compatible with chemical peritonitis have been reported. Over the period of a few months (January 2002-May 2002), a remarkable increase in the number of continuous ambulatory peritoneal dialysis (CAPD) patients using icodextrin dialysate diagnosed with sterile peritonitis was observed in our unit. METHODS: Five of the CAPD patients using icodextrin dialysate in our unit and diagnosed with sterile peritonitis were screened for leucocyte count and leucocyte differentiation during a follow-up period of 77 +/- 23 days. In addition, expression of CD14, a receptor for lipopolysaccharide (LPS), on the peripheral and peritoneal monocyte population was analysed. These results were compared to CAPD patients suffering from bacterial peritonitis. RESULTS: The peritoneal leucocyte count of CAPD patients using icodextrin dialysate and diagnosed with sterile peritonitis did not decrease significantly before treatment with icodextrin dialysate was interrupted, whereas it currently disappeared within 2-4 days in proven bacterial peritonitis. The sterile, cloudy icodextrin effluent contained an excess of macrophages on the day of diagnosis, whereas in bacterial peritonitis essentially an increase in the granulocyte population was observed. No elevation in the eosinophil population was observed. In contrast to bacterial peritonitis, we observed no increase in CD14 expression on the peripheral and peritoneal macrophages on the day of presentation and during the follow-up period. CONCLUSIONS: Specific batches of the icodextrin CAPD fluids contain a macrophage chemotactic agent, which causes a sustained inflammatory state in the peritoneal cavity. Because no increase in the expression of the LPS receptor CD14 could be observed, the increased peritoneal leucocyte count is probably not caused by LPS or LPS-like (possibly peptidoglycan-like) contamination.     

Effects of icodextrin in automated peritoneal dialysis on blood pressure and bioelectrical impedance analysis.

BACKGROUND: Glucose absorption from glucose-based dialysis fluids limits ultrafiltration from the daytime dwell in automated peritoneal dialysis (APD). Icodextrin may allow greater ultrafiltration during the daytime period in APD, enhancing fluid control. METHODS: A 7.5% icodextrin dialysate was compared with a 2. 27% glucose dialysate for the daytime dwell in 14 subjects on APD. Blood pressure, weight and body water compartments estimated by multifrequency bioelectrical impedance (MFBIA) were determined in subjects using 2.27% glucose as the daytime dwell and then repeated 1 month after switching to icodextrin. RESULTS: Icodextrin resulted in symptomatic hypotension requiring reduction of antihypertensive medication in six of the 14 patients. Despite this reduction in treatment, systolic blood pressure fell from 142.4 (23.9) mmHg to 122.9 (17.7) mmHg, P<0.005, and diastolic blood pressure tended to fall from 82.8 (9.8) mmHg to 76.8 (10.1) mmHg, P=0.075. Change in systolic blood pressure significantly correlated with changes in weight (r=0.62, P<0.05) and MFBIA estimates of total body water (TBW) (r=0.56, P<0.05), extracellular water (ECW) (r=0.79, P<0.002), extra/intracellular water ratio (ECW/ICW) (r=0.72, P<0.01) and derived resistances R(ecf) of ECW (r=-0.69, P<0.01) and R(inf) of TBW (r=-0.66, P<0.02). Changes in diastolic blood pressure significantly correlated with changes in ECW (r=0.64, P<0.02) and ECW/ICW ratio (r=0.58, P<0.05), and almost significantly with R(ecf) (r=-0.51, P=0.08) and R(inf) (r=-0.52, P=0.07) estimated by MFBIA, but not with changes in weight or TBW. CONCLUSIONS: Use of icodextrin for the daytime dwell in APD results in improved fluid balance and blood pressure control compared with 2.27% glucose. MFBIA detected clinically important changes in fluid content in these patients.     

Significant hypoglycemia secondary to icodextrin peritoneal dialysate in a diabetic patient

Icodextrin, a peritoneal dialysate commonly used in the renal failure patient with diabetes, may lead to an overestimation of blood glucose levels as determined by bedside glucometers. This spurious hyperglycemia can lead to significant morbidity if unrecognized. We describe a case of severe hypoglycemia caused by an unappreciated overestimation of blood glucose in a diabetic patient with concomitant chronic renal failure requiring peritoneal dialysis with icodextrin.     

Predictors of a favourable response to icodextrin in peritoneal dialysis patients with ultrafiltration failure

BACKGROUND AND AIMS: Icodextrin is a starch-derived glucose polymer that causes sustained ultrafiltration in long dwells in peritoneal dialysis. The aim of this study was to assess factors that were predictive of an increment in ultrafiltration following the introduction of icodextrin in patients with refractory fluid overload. METHODS: Thirty-nine patients (20 male/19 female, mean age 57.7 +/- 2.4 years) on peritoneal dialysis were enrolled in a prospective pretest/post-test, open-label study. All patients had symptomatic fluid overload refractory to fluid restriction (<800 mL/day), frusemide doses of 250 mg or more daily, optimization of dwell time and use of hypertonic dextrose. An icodextrin exchange was substituted for a 4.25% dextrose exchange for the long-dwell period. RESULTS: After 1 month, median (interquartile range) 24 h ultrafiltration volume increased by 500 mL (interquartile range: 50-1000). An increase in ultrafiltration volume correlated positively with the dialyate : plasma creatinine ratio at 4 h (r = 0.498, P = 0.001) and negatively with the ratio of dialysate glucose concentrations at 4 and 0 h (r = -0.464, P = 0.003). On multivariate regression analysis, high transporter status was predictive of a greater ultrafiltration response to icodextrin relative to dextrose peritoneal dialysis exchanges. Age, sex, race, peritoneal dialysis duration, peritoneal dialysis modality, diabetes mellitus, baseline albumin, and baseline ultrafiltration volume were not significantly correlated with the change in ultrafiltration volume. CONCLUSION: Icodextrin significantly augments ultrafiltration volumes in patients with refractory fluid overload. A high peritoneal membrane transporter status is the best predictor of a favourable ultrafiltration response to icodextrin.     

Peritoneal clearance of homocysteine with icodextrin or standard glucose solution exchange

BACKGROUND: The aim of the study was to assess plasma homocysteine concentration in peritoneal dialysis patients, and to compare the effect of different peritoneal solutions (glucose-based and icodextrin-based) on peritoneal clearance of homocysteine. METHODS: The study group comprised 10 chronic peritoneal dialysis patients; the control group comprised 15 healthy, age-matched non-obese subjects with normal renal function. Patients with vitamin B(12) or folate deficiency were excluded. In all subjects, plasma homocysteine and dialysis adequacy parameters were assessed at baseline. The clearance study was carried out with 2.27% glucose and 7.5% icodextrin solutions (12-h dwell time). RESULTS: Mean dialysate concentration of homocysteine was similar for both glucose and icodextrin solutions (8.3 +/- 3.2 and 8.4 +/- 1.9 micromol/L, respectively), but homocysteine clearance was significantly higher for icodextrin than glucose solution (1.82 +/- 0.57 vs 1.39 +/- 0.53 mL/min per 1.73 m(2)P = 0.01). Net ultrafiltration after icodextrin solution was also higher than after glucose solution (599 +/- 136 mL vs 134 +/- 337 mL, P < 0.01). A correlation between total plasma level of homocysteine and its peritoneal clearance was found (r = 0.69; P = 0.03). CONCLUSION: It appears that peritoneal elimination of homocysteine depends primarily on its plasma concentration. Icodextrin-based solution for peritoneal dialysis seems to be more efficient in homocysteine elimination than a standard glucose-based solution.     

Icodextrine and insulin resistance in continuous ambulatory peritoneal dialysis patients

Insulin resistance is commonly observed in uremic patients. Glucose-based peritoneal dialysis solutions have long-term metabolic complications like hyperinsulinemia, hyperlipidemia, and obesity. The purpose of this study was to examine the insulin resistance in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) with standard glucose and icodextrin containing solutions. The entire non diabetic CAPD patients of our center were studied: forty-four patients in all who were on CAPD treatment for 36.2 +/- 23.7 months. Twenty-seven of them (11 male and 16 female) with a mean age of 46 +/- 16 years were treated with standard glucose solutions (glucose group). The other 17 patients (10 male and 7 female) with a mean age of 49 +/- 16 years were treated with standard glucose solutions during the day and icodextrin dwell during the night, for a median of 12 +/- 6.3 months (icodextrin group). Morning fasting serum insulin levels were 20.59 +/- 17.86 in the glucose group and 10.15 +/- 6.87 in the icodextrin group (p = 0.0001). Homeostasis Model Assessment Method scores of the glucose group were significantly higher (4.8+/-4.1 vs 2.3+/- 1.7; p = 0.025) than the icodextrin group. A significant positive correlation of HOMA score with insulin, fasting plasma glucose, and triglyceride levels were found in HOMA (IR+) patients. Twenty patients of the icodextrin group (74%) and 15 patients of the glucose group (88%) were hypertensive, but there was no statistically significant difference between the two groups (p = 0.13). The groups showed no significant differences for body mass index and serum levels of glucose, total cholesterol, LDL cholesterol, VLDL cholesterol, HDL cholesterol, triglyceride, intact parathyroid hormone (iPTH), and fibrinogen. In conclusion, the use of icodextrin in the long nighttime dwell can reduce serum insulin levels and increase insulin sensitivity in CAPD patients.     

Icodextrine and Insulin Resistance in Continuous Ambulatory Peritoneal Dialysis Patients

Insulin resistance is commonly observed in uremic patients. Glucose-based peritoneal dialysis solutions have long-term metabolic complications like hyperinsulinemia, hyperlipidemia, and obesity. The purpose of this study was to examine the insulin resistance in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) with standard glucose and icodextrin containing solutions. The entire non diabetic CAPD patients of our center were studied: forty-four patients in all who were on CAPD treatment for 36.2 ± 23.7 months. Twenty-seven of them (11 male and 16 female) with a mean age of 46 ± 16 years were treated with standard glucose solutions (glucose group). The other 17 patients (10 male and 7 female) with a mean age of 49 ± 16 years were treated with standard glucose solutions during the day and icodextrin dwell during the night, for a median of 12 ± 6.3 months (icodextrin group). Morning fasting serum insulin levels were 20.59 ± 17.86 in the glucose group and 10.15 ± 6.87 in the icodextrin group (p = 0.0001).

Homeostasis Model Assessment Method scores of the glucose group were significantly higher (4.8±4.1 vs 2.3± 1.7; p = 0.025) than the icodextrin group. A significant positive correlation of HOMA score with insulin, fasting plasma glucose, and triglyceride levels were found in HOMA (IR+) patients. Twenty patients of the icodextrin group (74%) and 15 patients of the glucose group (88%) were hypertensive, but there was no statistically significant difference between the two groups (p = 0.13). The groups showed no significant differences for body mass index and serum levels of glucose, total cholesterol, LDL cholesterol, VLDL cholesterol, HDL cholesterol, triglyceride, intact parathyroid hormone (iPTH), and fibrinogen. In conclusion, the use of icodextrin in the long nighttime dwell can reduce serum insulin levels and increase insulin sensitivity in CAPD patients.     

Icodextrin use in CCPD patients during peritonitis: ultrafiltration and serum disaccharide concentrations

Background and methods: In a randomized study on the biocompatibility of icodextrin (I) versus glucose (G) in CCPD we used icodextrin or glucose for the long daytime dwell. During the night-time dwells glucose was used in all patients. In case of peritonitis icodextrin was continued. In all patients ultrafiltration (UF) was recorded and serum icodextrin metabolites were determined every 3 months and during peritonitis in I-users when available. Results: Thirty-eight patients (19 G, 19 I) entered the study and suffered 30 peritonitis episodes (16 G, 14 I). During peritonitis (P), daytime dwell UF decreased significantly in G (P=0.001), but remained stable in I patients compared to non-peritonitis (NP) episodes. Total 24-h UF decreased in G (P=0.001) and in I patients (P=0.04), as the result of a decreased daytime UF and night-time UF, respectively. There was no difference in the used glucose concentrations during the P versus NP episodes. In five I-patients serum disaccharides increased from 0.05±0.01 to 1.26±0.23 mg/ml during follow up. During peritonitis serum disaccharide concentrations did not increase further (1.47±0.24 mg/ml, P=0.56). In I patients total carbohydrate minus glucose rose to 5.72±1.2 mg/ml during follow up, and to 6.63±1.04 mg/ml during peritonitis (P=0.7). These concentrations are comparable to CAPD patients despite the longer dwelltime in CCPD (8-10 versus 14-16 h, respectively). Adverse reactions attributable to icodextrin were not encountered. Conclusions: In contrast to glucose, icodextrin preserved the daytime dwell ultrafiltration during peritonitis. Serum icodextrin metabolites increased during icodextrin use, but remained stable during peritonitis. Adverse effects were not observed. Key words: disaccharides; icodextrin; maltose; peritoneal dialysis; peritonitis; ultrafiltration      

Recommendations for the use of icodextrin in peritoneal dialysis patients

SUMMARY: Icodextrin is a starch-derived, high molecular weight glucose polymer, which has been shown to promote sustained ultrafiltration equivalent to that achieved with hypertonic (3.86%/4.25%) glucose exchanges during prolonged intraperitoneal dwells (up to 16 h). Patients with impaired ultrafiltration, particularly in the settings of acute peritonitis, high transporter status and diabetes mellitus, appear to derive the greatest benefit from icodextrin with respect to augmentation of dialytic fluid removal, amelioration of symptomatic fluid retention and possible prolongation of technique survival. Glycaemic control is also improved by substituting icodextrin for hypertonic glucose exchanges in diabetic patients. Preliminary in vitro and ex vivo studies suggest that icodextrin demonstrates greater peritoneal membrane biocompatibility than glucose-based dialysates, but these findings need to be confirmed by long-term clinical studies. This paper reviews the available clinical evidence pertaining to the safety and efficacy of icodextrin and makes recommendations for its use in peritonal dialysis.     

Superiority of icodextrin compared with 4.25% dextrose for peritoneal ultrafiltration

Several clinical observations suggest the superiority of icodextrin compared with 4.25% dextrose in optimizing peritoneal ultrafiltration (UF), but no rigorous controlled evaluation has hitherto been performed. For comparing icodextrin and 4.25% dextrose during the long dwell of automated peritoneal dialysis, a multicenter, randomized, double-blind trial was conducted in 92 patients (control, 45; icodextrin, 47) with 4-h dialysate to plasma ratio creatinine >0.70 and D/D(0) glucose <0.34. Long-dwell net UF and the UF efficiency ratio (net UF volume per gram of dialysate carbohydrate absorbed) were determined at baseline, week 1, and week 2. The control and treatment groups were comparable at baseline (all patients using 4.25% dextrose for the long dwell) with regard to mean (+/-SEM) net UF (201.7 +/- 103.1 versus 141.6 +/- 75.4 ml, respectively; P = 0.637) and the percentage of patients with negative net UF (control, 37.8%; treatment, 42.6%; P = 0.641). During the study period, net UF was unchanged from baseline in the control group but increased significantly (P < 0.001) in the icodextrin group from 141.6 +/- 75.4 to 505.8 +/- 46.8 ml at week 1 and 540.2 +/- 46.8 ml at week 2. In the icodextrin group, the incidence of negative net UF was significantly lower (P < 0.0001) than in the control group. Findings were similar for UF efficiency ratio. Rash was reported significantly more often in the icodextrin group. This study showed that in high-average and high transporters, icodextrin is superior to 4.25% dextrose for long-dwell fluid and solute removal.     

Comparison of peritoneal equilibrium test with icodextrin and 2.5% glucose dialysis solutions

BACKGROUND: Icodextrin provides a different ultrafiltration mechanism than glucose-based dialysate. METHODS: To evaluate the difference in the peritoneal equilibrium test (PET) with regard to using icodextrin (Ico-PET) and glucose dialysate we designed a prospective study using Ico-PET and 2 cross-over conventional 2.5% glucose-based dialysate PETs (Gluco 1-PET and Gluco 2-PET) administered 3 months before and after the Ico-PET in 58 chronic peritoneal dialysis patients. RESULTS: More patients demonstrated higher transport types with the Ico-PET than the Gluco 1-PET and Gluco 2-PET (p<0.001). After a dwell time of 4 hours, the Ico-PET did not show an ultrafiltration benefit compared with the Gluco-PET (272.8 +/- 137.1 mL vs. 348.3 +/- 215.2 mL, p<0.001). The Ico-PET not only showed significantly higher values in the 0-hour, 2-hour and 4-hour dialysate to plasma creatinine concentration ratio (D/P Cr) than those of the Gluco 1-PET (p=0.029 and p<0.001, respectively), but also showed higher values in the 0-hour and 4-hour D/P Cr than those of the Gluco 2-PET (both p<0.001). The total ultrafiltration volume was positively correlated with the 4-hour D/P Cr with the Ico-PET (r=0.41, p=0.001), but the correlation was negative with the Gluco 1-PET (r=-0.33, p=0.012) and Gluco 2-PET (r=-0.51, p<0.001). The ratio of the glucose concentration in the outflow dialysate compared with baseline level (D/Do glucose), was also significantly higher with the Ico-PET than with the Gluco 1-PET and Gluco 2-PET after both 2 and 4 hours (both p<0.001). CONCLUSIONS: The Ico-PET showed a completely different result from the conventional Gluco-PET. The Ico-PET provi-des a superior solute transport and inferior ultrafiltration rates, and the prevalence of high transporters was also increased with the Ico-PET.     

The effect of icodextrin and glucose-containing solutions on insulin resistance in CAPD patients

PURPOSE: Peritoneal dialysis patients have particular risks with respect to their lipid status and hyperinsulinemia. The aim of this study was to investigate the relation between insulin resistance and the type of the peritoneal dialysis solution. MATERIALS: 41 randomly selected non-diabetic patient cohort who were already under treatment with continuous ambulatory peritoneal dialysis (CAPD) and 10 healthy controls participated in the study. 24 of the 41 patients were using 3 standard 1.36% glucose solutions during the day and 1 hypertonic solution with 2.27% glucose dwell during the night (glucose group: mean age 45.54 +/- 16.67 years and median CAPD duration 16.5 months). The remaining 17 patients were using 3 standard 1.36% glucose solutions during the day and 1 icodextrin dwell during the night for 8-10 hours (icodextrin group: mean age 47.47 +/- 13.15 years, median duration of icodextrin use 6 months (range 2-20 months), and median CAPD duration 30 months). Insulin resistance (IR) was calculated according to the homeostasis model assesment (HOMA) formula: HOMA-IR = fasting glucose (mmol/l) x fasting insulin (microU/1/22.5. The HOMA cutoff point for diagnosis of insulin resistance was established with receiver-operating characteristic (ROC) curves. The patients were called HOMA-IR(+) if their HOMA scores were higher than cutoff value. RESULTS: There were no significant differences between age, BMI, triglyceride, total and high-density lipoprotein (HDL) cholesterol, iron and ferritin, alanine aminotransferase, fibrinogen, intact parathyroid hormone, magnesium, hemoglobin and hematocrit levels of the 2 groups. The mean glucose levels of the groups were not different but fasting insulin levels and HOMA scores of the icodextrin group were significantly lower than the glucose group (10.15 +/- 6.87 vs. 18.11 +/- 13.15, p = 0.028, and 2.28 +/- 1.67 vs. 4.26 +/- 3.27, p = 0.027, respectively). The ratio of patients with low HOMA scores (cutoff = 2.511) were significantly higher in the icodextrin group than in the glucose group (71% vs 38%, p = 0.037). Other than fasting insulin and glucose levels, significantly positive correlation was found between HOMA score and BMI in both groups. With regression analysis, we found that the main parameters effecting HOMA score were BMI (p = 0.008) and triglyceride (p = 0.029) in the glucose group, but no parameters were found to affect HOMA score in icodextrin group. CONCLUSION: These results suggest that insulin resistance is reduced in peritoneal dialysis patients using icodextrin-based dialysis fluid instead of glucose-based dialysis fluid.     

Impact of fill volume on ultrafiltration with icodextrin in children on chronic peritoneal dialysis

Background

Icodextrin is a solution of glucose polymers developed to provide sustained ultrafiltration over an extended dwell. Our aim was to determine whether or not fill volume with icodextrin contributes to the ability to achieve ultrafiltration in children.

Methods

The charts of all children on chronic peritoneal dialysis between January 2000 and July 2014 were screened for the use of an icodextrin day dwell. Data were extracted from the electronic chart and the HomeChoice? Pro card and corrected for body surface area (BSA).

Results

Fifty children had an icodextrin day dwell. A linear correlation was found between the daytime fill volume and net ultrafiltration (p?<?0.001). More ultrafiltration was achieved with a fill volume above 550 ml/m² BSA (107?±?75 ml/m² BSA) than with smaller fill volumes (?8?±?99 ml; p?=?0.004). Ultrafiltration was achieved in 88 % of children with a fill volume above 550 ml/m² BSA versus only 44 % of patients with a smaller fill volume (p?=?0.001). Icodextrin was well tolerated.

Conclusions

Our observations reveal that the larger the fill volume the higher the likelihood of achieving ultrafiltration with icodextrin and suggest that a minimum day dwell volume of 550 ml/m² BSA seems to facilitate ultrafiltration in children. To our knowledge this is the largest study addressing ultrafiltration with icodextrin in children.

     

腹膜转运特性明显影响艾考糊精腹透液的超滤量

目的 观察不同腹膜转运特性的患者使用7.5%艾考糊精腹透液长时间留腹后的超滤量。 方法 采用前瞻性、多中心、随机、双盲和平行对照临床研究的亚组分析。连续非卧床腹膜透析（CAPD）患者根据腹透液肌酐与血肌酐比值（D/Pcr）和Twardoski的评判标准,分为高转运、高平均转运、低平均转运和低转运4组。患者分别使用7.5%艾考糊精透析液或2.5%葡萄糖 Dianeal?誖 PD-2、PD-4透析液,疗程4周。比较各组超滤量。 结果 共201例CAPD患者入选,其中艾考糊精组98例,葡萄糖组103例;男96例,女105例;年龄（56.1±13.7）岁（18～81岁）。198例进行了腹膜平衡试验,其中高转运患者24例（12.1%）,高平均转运72例（36.2%）,低平均转运81例（40.7%）,低转运21例（11.0%）。治疗第4周,高转运、高平均转运和低平均转运患者中,艾考糊精组超滤量显著升高,无论与基线值还是与葡萄糖组比较,差异都有统计学意义;而低转运患者中,艾考糊精组超滤量高于葡萄糖组,但差异无统计学意义。相关分析显示,艾考糊精腹透液产生的超滤量与D/Pcr呈正相关（R2 = 0.1681,P < 0.01）,而葡萄糖透析液产生的超滤量与D/Pcr呈负相关（R2 = 0.0949,P < 0.01）。 结论 7.5%艾考糊精腹透液可显著改善CAPD患者的超滤量和腹膜肌酐清除率,尤其在腹膜高转运、高平均转运和低平均转运患者,其作用显著优于葡萄糖腹透液。