Improving Patient Outcomes with High Performance PD Solution
Outlines • Introducing Icodextrin • Biochemical properties • Mechanism of action • Potential & evidence-based clinical benefits of Icodextrin • Improve ultrafiltration, decrease episode of fluid overload/CHF? • Improve metabolic/glycemic control? • Improve PD survival, decrease mortality? • My experience
4. Icodextrin and Residual Renal Function Wolfson et al. Plum et al. Davies et al. Konings et al. Takatori et al. AJKD 2002 AJKD 2002 JASN 2003 KI 2003 CJASN 2011 4-week 12-week F/U & study multicenter multicenter 6-mo 4-mo single 2-yr design multicenter center RCT multicenter RCT RCT Sample size RCT 40 RCT 175 39 50 41 PD modality CAPD APD CAPD/APD CAPD/APD CAPD/APD Comparison 2.5% dextrose 2.27% glucose 2.27% glucose glucose in long 1.5% or 2.5% group long dwell long dwell long dwell dwell dextrose long dwell Residual renal function
4. Icodextrin and Residual Renal Function In low certainty, icodextrin may make little or no difference to RRF. Favor standard glucose Favor icodextrin Htay H, et al. Cochrane Database Syst Rev 2018; 2018(10): CD007554
4. Icodextrin and Residual Renal Function In low certainty, icodextrin-induced increase in peritoneal UF may make little or no difference to daily urine volume. Favor standard glucose Favor icodextrin Htay H, et al. Cochrane Database Syst Rev 2018; 2018(10): CD007554
Icodextrin and metabolic complications
5. Icodextrin and Weight Gain Is icodextrin zero in calories? 4.25% dextrose 2.5% dextrose 7.5% icodextrin CHO per 2 L (g) 77.2 45.5 150 % absorbed after 8-h dwell 86% 86% 25% CHO absorbed (g) 66 39 37.5 Kcal/dwell 266 156 150
5. Icodextrin and Weight Gain A 12-month RCT from Maxico in 59 DM CAPD patient (ICO = 30, Glucose = 29) glucose icodextrin Stable BW in icodextrin group Paniagua et al. Perit Dial Inter 2009; 29: 422-32
5. Icodextrin and Weight Gain
6. Icodextrin and Glycemic Control oral glucose 4.25% PDF “Oral glucose loading and IP administration of 4.25% dextrose result in increased plasma glucose and insulin release in similar fashion”. Gokal R, et al. Kidney Inter 2002; 62(81): S62-71
6. Icodextrin and Glycemic Control In contrast, IP administration of icodextrin does not cause an increase in plasma glucose or insulin response. Gokal R, et al. Kidney Inter 2002; 62(81): S62-71
6. Icodextrin and Glycemic Control Reduced CHO load in icodextrin group was associated with lower fasting plasma glucose, HbA1c, and fasting TG in DM CAPD patients at 12 months. Paniagua et al. Perit Dial Inter 2009; 29: 422-32
6. Icodextrin and Glycemic Control A Multinational RCT of 251 PD patients with DM • IMPENDIA (Physioneal + Extraneal + Nutrineal vs Dianeal) • EDEN (Dianeal + Extraneal + Nutrineal vs Dianeal) • Mean HbA1c improved in study groups but remained unchanged in the control group. • Serum triglyceride, LDL, apolipoprotein B also improved in the intervention group. Li PK, et al. J Am Soc Nephrol 2013; 24: 1889-1900
7. Icodextrin and Technique Survival Open-label single arm study: 39 PD patients with refractory fluid overload, planning to shift to HD —> extended PD with icodextrin • Icodextrin improved UF by 368 mL/day • Prolonged PD by 1.21 years (95% CI 0.80-1.62) • Extension was marked (1.7 years) in patients with UF failure at entry Johnson DW, et al. Advances in Peritoneal Dialysis 2003
Icodextrin in Thailand 100 % of patients 75 59 57 60 55 50 25 UK 26 US 1 0 A/NZ Canada Japan Thailand
Icodextrin use at KCMH? PD Modalities Icodextrin Users CAPD Yes 39% 13% APD 61% No 87%
Icodextrin improves long-dwell UF Extraneal® for APD Extraneal® for CAPD
Icodextrin - Internation Guidelines
Icodextrin improves long-dwell UF Woodrow et al. BMC Nephrology 2017; 18: 333
Icodextrin improves long-dwell UF Wang AYM et al. Perit Dial Inter 2015; 33: 379-87
My Experience
A 60-year-old female with T2DM • ESRD due to DN, HT, DLP • On CAPD for 3 years, no RRF • Uncontrolled BP, refractory edema • Good compliance • Kt/V 1.75, other labs OK • Current prescription: • 1.5% dextrose 2 L x 3 (daytime) • 2.5% dextrose 2 L x 1 (night time) • 4.25% dextrose 2 L 3-4 times/wk • UF 500 mL/day What would you do?
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