International Icodextrin Use and Association with Peritoneal Membrane Function, Fluid Removal, Patient and Technique Survival

Abstract

Key Points There are important national and center differences in the prescription of icodextrin, with the United States a clear outlier; across all countries, icodextrin was more likely to be used if membrane function tests indicated reduced ultrafiltration capacity to glucose.This large, international observational study was unable to show patient or hemodialysis transfer advantages to icodextrin use.Where use of icodextrin was low, this was compensated for by much greater use of high glucose and overall higher ultrafiltration volumes at each level of urine volume; this practice may confound associations between icodextrin and survival outcomes. Background Icodextrin has been shown in randomized controlled trials to benefit fluid management in peritoneal dialysis (PD). We describe international icodextrin prescription practices and their relationship to clinical outcomes. Methods We analyzed data from the prospective, international PDOPPS, from Australia/New Zealand, Canada, Japan, the United Kingdom, and the United States. Membrane function and 24-hour ultrafiltration according to icodextrin and glucose prescription was determined at baseline. Using an instrumental variable approach, Cox regression, stratified by country, was used to determine any association of icodextrin use to death and permanent transfer to hemodialysis (HDT), adjusted for demographics, comorbidities, serum albumin, urine volume, transplant waitlist status, PD modality, center size, and study phase. Results Icodextrin was prescribed in 1986 (35%) of 5617 patients, >43% of patients in all countries, except in the United States, where it was only used in 17% and associated with a far greater use of hypertonic glucose. Patients on icodextrin had more coronary artery disease and diabetes, longer dialysis vintage, lower residual kidney function, faster peritoneal solute transfer rates, and lower ultrafiltration capacity. Prescriptions with or without icodextrin achieved equivalent ultrafiltration (median 750 ml/d [interquartile range 300–1345 ml/d] versus 765 ml/d [251–1345 ml/d]). Icodextrin use was not associated with mortality (HR=1.03; 95% CI, 0.72 to 1.48) or HDT (HR 1.2; 95% CI, 0.92 to 1.57). Conclusions There are large national and center differences in icodextrin prescription, with the United States using significantly less. Icodextrin was associated with hypertonic glucose avoidance but equivalent ultrafiltration, which may affect any potential survival advantage or HDT.