Clinical Benefits of Low-glucose Peritoneal Dialysis Fluid Regimens in patients with elevated transport function.13,14 In a recent
meta-analysis of several clinical studies, the superior ultrafiltration and small-solute clearance (e.g. creatinine and urea nitrogen) using icodextrin compared with glucose-based PD solutions was confirmed.15
Importantly, it has also been demonstrated that, during peritonitis, ultrafiltration is better preserved with icodextrin than with a glucose-based PDF, as demonstrated in CAPD19
children treated with CCPD,16 with CAPD,17 diabetes.18
and CCPD.10 In
fact, patients on a glucose-only-based regimen can be temporarily switched to icodextrin for the long dwell in order to better maintain ultrafiltration and to reduce glucose absorption through the inflamed peritoneal membrane.
Fortunately, the improved ultrafiltration seen with icodextrin use is not associated with a faster decline in urinary output or residual renal clearance, as demonstrated in a number of studies20,21 above mentioned meta-analysis.15
and in the In addition, several studies
demonstrated that treatment with icodextrin actually resulted in an improved fluid status12,22–24
reduction in left ventricular mass.23,25
and appeared to be associated with a The observation that icodextrin
had a reduced detrimental effect on peritoneal membrane function in the European automated peritoneal dialysis outcomes study (EAPOS)26 is in line with these clinically observed improved effects of icodextrin compared with glucose-based solutions.
Icodextrin use resulted in a lower increase in body weight and fat accumulation compared with glucose-based solutions.10,27,28
Several
other metabolic advantages of icodextrin over glucose have been reported. Firstly, icodextrin-treated patients had a better serum lipid profile than patients who were only treated with glucose-based solution lipids,25,29–31 icodextrin is not reported in all studies.32
although this benefit of Secondly, an improvement
Thirdly, there may be particular benefits for the diabetic PD patient; in a randomised controlled trial, use of icodextrin for the long dwell led to improved glycaemic control in diabetic CAPD patients, driven by the reduced glucose load in the CAPD therapy regimen (see Figure 1).35
sensitivity has been described during icodextrin treatment.36
Finally, better erythropoietin These
metabolic advantages may lead to a better outcome for PD patients during treatment with icodextrin.
The use of icodextrin is associated with elevated levels of glucose polymer breakdown products, which in turn is associated with a slight decrease in serum sodium concentration.28,37
After withdrawal
of icodextrin, the breakdown products disappear quickly from the circulation.28
although this rise in
CML did not result in increased levels of vascular cell adhesion molecule-1 (VCAM-1).39
encapsulating peritoneal sclerosis (EPS),43
Contrary to what was anticipated, the use of icodextrin was associated with an increase in the advanced glycation end-product N(ε)-(carboxymethyl)lysine (CML),38
Whether this rise in CML has a
pathophysiological meaning is a point that remains to be established. Similarly, it has not been completely resolved whether icodextrin treatment is associated with an improvement in the inflammatory status of the peritoneal membrane40 associated with an increased inflammatory response.41,42
or whether it is Recently,
icodextrin use, and in particular the length of icodextrin treatment, has been associated with an increased risk of developing
EUROPEAN NEPHROLOGY although it remains to be
established whether there is a causal relationship between icodextrin use and this untoward complication of PD, or whether it merely reflects that patients with ultrafiltration problems and/or elevated membrane transport characteristics are at increased risk of developing EPS. Such possible association of icodextrin with EPS, however, is more a demand for further research rather than advocating reduced application of PD and/or icodextrin use to prevent this infrequent, albeit fearful, complication of PD. Indeed, whereas icodextrin use may have some potentially negative side effects, several papers have shown, over the past few years, better technique and patient survival in PD patients treated with icodextrin. Kuriyama et al.44
demonstrated not only that the dropout rate of PD 49
in insulin resistance was observed during treatment with icodextrin.29,31,33–35
C
1.5 2.0
-0.5 0.5
0.0 1.0
-1.0 -1.5
-2.5 -2.0
36 Months
HbA1c = glycated haemoglobin; *p<0.05; + Source: Paniagua et al., 2009,35
p<0.01. originally published in Peritoneal Dialysis International. * * + 9 12 + B 100 50
-200 -150 -100 -50 0
36 Months and may also be especially beneficial for patients with
Figure 1: Reduced Glucose Load Was Associated with Lower Levels of Fasting Serum Glucose (A), Serum Triglycerides (B) and Glycated Haemoglobin (C) in Patients using Icodextrin-based Dialysis Solution (Blue Dots) versus Glucose-based Solutions (Red Dots)
Such improved ultrafiltration has also been observed in as well as in elderly patients treated
A 100
50 75
25 0
-25 -50 -75
-100
369 12 Months
* *
+ +
9
12
∆HbA1c
(%)
∆Serum triglycerides (mg/dL)
∆Fasting serum glucose (mg/dL)
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