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

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 analysed data from the prospective, international PDOPPS, from Australia/New Zealand, Canada, Japan, United Kingdom, and United States (US). 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 1,986 (35%) of 5,617 patients, over 43% of patients in all countries except in the US, 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 [Interquartile range 300-1345] vs. 765 [251,1345] mL/day). Icodextrin use was not associated with mortality (HR 1.03, 95% CI: 0.72, 1.48) or HDT (HR 1.20, 95% CI: 0.92, 1.57). Conclusions: There are large national and center differences in icodextrin prescription, with the US using significantly less. Icodextrin was associated with hypertonic glucose avoidance but equivalent ultrafiltration, which may impact any potential survival advantage or impact on HDT.